How are fibromyalgia symptoms managed?

Management of Fibromyalgia Symptoms

Begin immediately with aerobic and strengthening exercise as the primary intervention, which has the strongest evidence (Level Ia, Grade A) for improving pain, function, and quality of life in fibromyalgia. 1

Non-Pharmacological Management (First-Line Treatment)

Exercise Protocol

• Start low-impact aerobic exercise (walking, swimming, cycling) at 20-30 minutes, 2-3 times weekly, gradually increasing to 30-60 minutes, 5 days weekly. 2
• Add progressive resistance training 2-3 times weekly after establishing aerobic exercise tolerance. 2
• All forms of exercise improve pain (effect size -0.72 to -0.96) and depression (effect size -0.35 to -1.22) except flexibility exercise alone. 3
• Mind-body and strengthening exercises specifically improve fatigue (effect size -0.77 to -1.00), while aerobic and strengthening exercises improve sleep (effect size -0.74 to -1.33). 3

Heated Pool Therapy

• Heated pool treatment with or without exercise is effective (Level IIa, Grade B evidence) and may improve exercise tolerance. 1, 2

Cognitive Behavioral Therapy

• Initiate CBT for patients with depression, anxiety, or maladaptive coping strategies (Level Ia, Grade A evidence). 1, 2
• CBT improves pain, sleep, and depression (effect size -0.35 to -0.55) but does not significantly improve fatigue. 3

Additional Effective Non-Pharmacological Therapies

• Acupuncture provides pain reduction (Level Ia, Grade A evidence). 1, 2
• Meditative movement therapies (tai chi, yoga, qigong) are beneficial (Level Ia, Grade A evidence). 1, 2
• Mindfulness-based stress reduction programs are recommended (Level Ia, Grade A evidence). 1, 2

Pharmacological Management (Second-Line Treatment)

Add pharmacological therapy only if non-pharmacological interventions provide insufficient symptom control after 4-6 weeks. 1

First-Line Medications

Amitriptyline

• Start 10-25 mg at bedtime for patients with prominent sleep disturbance and pain. 1, 2
• Titrate by 10-25 mg weekly to 50-75 mg as tolerated (Level Ia, Grade A evidence). 1, 2
• Number needed to treat for 50% pain relief is 4.1. 1

Duloxetine

• Start 30 mg daily for 1 week, then increase to 60 mg daily for patients with pain plus depression or anxiety (Level Ia, Grade A evidence). 1, 2
• Do not escalate beyond 60 mg/day—no additional benefit but increased adverse events. 1
• Approximately 50% of patients achieve at least 30% pain reduction. 1

Pregabalin

• Start 75 mg twice daily (150 mg/day), titrate to 150 mg twice daily (300 mg/day) over 1 week for patients with predominant pain without mood symptoms (Level Ia, Grade A evidence). 1, 2, 4
• Patients without sufficient benefit at 300 mg/day may increase to 225 mg twice daily (450 mg/day). 4
• Do not exceed 450 mg/day—no additional benefit but increased dose-dependent adverse reactions. 1, 4

Milnacipran

• Recommended dose is 100-200 mg/day in divided doses (Level Ia, Grade A evidence). 1
• Start with dose escalation over approximately 1 week to minimize side effects. 1
• Provides similar efficacy to duloxetine for pain reduction and small but significant benefits on fatigue and disability. 1

Second-Line Medications

Tramadol

• Use tramadol (Level Ib, Grade A evidence) only when first-line medications are ineffective. 1

Cyclobenzaprine

• Can be considered for pain management (Level Ia, Grade A evidence). 1

Critical Medications to Avoid

• Corticosteroids have no role in fibromyalgia treatment (Level Ia, Grade A evidence). 1, 2
• Strong opioids (morphine, oxycodone, hydrocodone) are not recommended—they lack demonstrated benefit and carry significant risks. 1, 2
• NSAIDs have limited to no benefit as monotherapy since fibromyalgia is not an inflammatory condition but rather a central sensitization disorder. 1, 5

Treatment Algorithm

1. Week 0: Begin aerobic exercise (20-30 minutes, 2-3 times weekly) and patient education about central sensitization mechanism. 1, 5, 2

2. Week 4-6: If insufficient response, add heated pool therapy, CBT (if mood symptoms present), or acupuncture. 1, 2

3. Week 6-8: If still insufficient response, initiate pharmacological therapy:

   • Sleep disturbance predominant → Amitriptyline 10-25 mg at bedtime 2
   • Depression/anxiety present → Duloxetine 30 mg daily, increase to 60 mg after 1 week 2
   • Pain predominant without mood symptoms → Pregabalin 75 mg twice daily, increase to 150 mg twice daily after 1 week 2

4. Week 12-16: Evaluate treatment response using pain scores (0-10 scale), functional status, and patient global impression of change. 2

5. If partial response: Consider adding a medication from a different class (e.g., amitriptyline + duloxetine). 1

6. If no response: Switch to alternative first-line medication from different class. 1

Monitoring and Reassessment

• Evaluate treatment response every 4-8 weeks using pain scores (0-10 scale), functional status, and patient global impression of change. 2
• Expect 30-50% pain reduction rather than complete resolution—most treatments show modest effect sizes. 1, 2
• Multicomponent therapy (combining exercise, CBT, and medication) may provide greater benefit than any single intervention. 1, 2

Common Pitfalls to Avoid

• Do not rely solely on pharmacological therapy without implementing exercise and behavioral approaches—exercise has the strongest evidence. 1, 2
• Do not diagnose fibromyalgia as a diagnosis of exclusion; it is a positive clinical diagnosis based on characteristic features of central sensitization. 5
• Do not escalate duloxetine beyond 60 mg/day or pregabalin beyond 450 mg/day—no additional benefit but increased adverse events. 1, 4
• Do not attribute symptoms to peripheral nerve damage—fibromyalgia is fundamentally a central nervous system disorder. 5