Management of Fibromyalgia in a 46-Year-Old Woman
This patient has fibromyalgia, and the best management approach is exercise as the only therapy with strong evidence, combined with patient education, followed by duloxetine or pregabalin for severe pain/sleep disturbance, and cognitive behavioral therapy if mood disorders or maladaptive coping are present. 1
Diagnosis
This clinical presentation is consistent with fibromyalgia based on:
- Widespread pain for nine months affecting multiple body regions (knees, trapezius, posterior cervical area) 1, 2
- Fatigue and sleep disturbance as prominent accompanying symptoms 1, 2
- Gastrointestinal symptoms (bloating, diarrhea) representing common comorbid functional somatic syndromes 1, 3
- Tender points on physical examination at characteristic anatomic sites 2, 4
- Absence of other abnormalities on examination, excluding inflammatory or structural pathology 5
The American College of Rheumatology criteria require widespread pain for at least three months and tenderness at 11 or more of 18 specific tender point sites 4. This patient meets these criteria with nine months of symptoms and documented tender points 2.
Staged Management Algorithm
Stage 1: Initial Management (All Patients)
Patient education is the essential first step, explaining that fibromyalgia is a real condition involving disordered pain processing, not structural damage, which reduces anxiety and unnecessary testing 1, 2.
Exercise is the only therapy with a "strong for" recommendation based on meta-analyses and should be initiated immediately 1. Begin with low-level activities and gradually increase intensity, as patients often resist exercise due to pain and fatigue 1. Aerobic exercise, strength training, or activities like yoga/tai chi can improve pain and function 1, 2.
Stage 2: Pharmacotherapy for Severe Pain or Sleep Disturbance
If non-pharmacological approaches are insufficient, add medication tailored to the most problematic symptoms (all have "weak for" recommendations based on meta-analyses) 1:
For pain and sleep disturbance:
- Duloxetine 60 mg once daily is FDA-approved and demonstrated statistically significant pain reduction in fibromyalgia trials, with some patients experiencing benefit as early as week 1 6, 2. The 120 mg dose showed no additional benefit over 60 mg and caused more adverse effects 6.
- Pregabalin 300-450 mg/day is FDA-approved and showed efficacy in reducing pain scores and improving patient global assessment 7, 2. The 600 mg dose provided no additional benefit over 450 mg 7.
- Amitriptyline (off-label) can be considered as an alternative 2.
Avoid NSAIDs and opioids as they have not demonstrated benefits for fibromyalgia and carry significant risks 2.
Stage 3: Psychological Interventions
Cognitive behavioral therapy (CBT) should be added for patients with mood disorders (anxiety, depression) or unhelpful coping strategies 1, 2. CBT can improve pain, function, and quality of life 1, 2.
Solution-focused therapy has shown benefit in reducing fatigue in similar chronic conditions, though effects may not persist after therapy discontinuation 1.
Stage 4: Multimodal Rehabilitation
For patients with severe disability despite the above interventions, consider a comprehensive multimodal rehabilitation program 1.
Essential Diagnostic Workup
Before confirming fibromyalgia, exclude organic diseases:
- Complete blood count to assess for anemia contributing to fatigue 8
- Comprehensive metabolic panel including electrolytes, renal and liver function 8
- Thyroid function tests (TSH, Free T4) as hypothyroidism mimics fibromyalgia symptoms 8
- Inflammatory markers (ESR, CRP) to exclude inflammatory rheumatic diseases 8
- Vitamin D, B12, and iron studies as deficiencies can cause similar symptoms 8
- Celiac disease screening given gastrointestinal symptoms 8
Common Pitfalls and Caveats
Do not over-investigate once fibromyalgia is diagnosed, as this reinforces illness behavior and increases healthcare costs 1, 2.
Do not use tender point examination alone for diagnosis, as the 1990 ACR criteria have limitations in clinical practice 5. Consider the broader symptom constellation including fatigue, sleep disturbance, and cognitive dysfunction 2, 3.
Recognize overlapping conditions: Fibromyalgia frequently coexists with irritable bowel syndrome (explaining the bloating and diarrhea), chronic fatigue syndrome, and mood disorders 3, 5. These are interconnected functional somatic syndromes sharing common pathophysiology 3.
Address sleep disturbance specifically, as disrupted sleep architecture is a core feature of fibromyalgia and perpetuates pain 1, 2. Evaluate for sleep apnea if indicated 1.
Monitor for psychiatric comorbidity: Depression and anxiety are more prevalent in fibromyalgia patients and require direct assessment and treatment 5, 4.
Avoid splinting or prolonged immobilization, which can worsen symptoms through deconditioning and learned non-use 1.
Set realistic expectations: Fibromyalgia is a chronic condition requiring ongoing management rather than cure 1, 2. The goal is symptom reduction and improved function, not complete pain elimination 1.