What are the treatment options for fibromyalgia?

Treatment Options for Fibromyalgia

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 patients. 1, 2

Initial Non-Pharmacological Management (First-Line)

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 once aerobic tolerance is established 2
• Exercise should be individually tailored and gradually increased based on tolerance to avoid symptom flare-ups 1
• Heated pool therapy or hydrotherapy provides additional benefit (Level IIa, Grade B) and may improve exercise tolerance 1, 2

Additional Non-Pharmacological Therapies

• Cognitive behavioral therapy (CBT) is recommended for patients with depression, anxiety, or maladaptive coping strategies (Level Ia, Grade A) 1, 2
• Acupuncture provides pain reduction (Level Ia, Grade A evidence) 1, 2
• Meditative movement therapies including tai chi, yoga, or qigong are beneficial (Level Ia, Grade A) 1, 2
• Mindfulness-based stress reduction programs improve symptoms and quality of life 1, 2
• Multicomponent therapies combining different approaches show significant benefit for overall symptom management 1

Pharmacological Management (Second-Line)

Add pharmacological therapy only if non-pharmacological interventions provide insufficient relief after 4-6 weeks. 1, 2

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) 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) 1, 2, 3
• Do not escalate beyond 60 mg/day—no additional benefit demonstrated at 120 mg/day but higher rates of adverse events 1, 3
• Approximately 50% of patients achieve at least 30% pain reduction 1

Pregabalin

• Start 75 mg twice daily, titrate to 150 mg twice daily over 1 week for patients with predominant pain without mood symptoms (Level Ia, Grade A) 1, 2, 4
• Maximum effective dose is 450 mg/day (150 mg three times daily or 225 mg twice daily) 1, 4
• Do not escalate beyond 450 mg/day—no evidence of greater effect at 600 mg/day but increased dose-dependent adverse reactions 1, 4
• Some patients experience pain decrease as early as Week 1 4

Second-Line Medications

Milnacipran

• Recommended dose is 100-200 mg/day given in divided doses (Level Ia, Grade A) 1
• Start at lower doses and titrate up over approximately 1 week to minimize side effects 1
• Effective for pain reduction and fatigue symptoms 1

Tramadol

• Consider for pain management (Level Ib, Grade A) when first-line medications are ineffective 1
• Use cautiously given opioid-related risks 1

Cyclobenzaprine

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

Critical Medications to Avoid

The following medications have no role in fibromyalgia treatment and should not be prescribed:

• Corticosteroids—no efficacy demonstrated (Level Ia, Grade A) 1, 2
• Strong opioids (morphine, oxycodone, hydrocodone)—lack demonstrated benefit and carry significant risks (Level Ia, Grade A) 1, 2
• NSAIDs as monotherapy—limited to no benefit since fibromyalgia is not an inflammatory condition 1, 2

Treatment Algorithm

Step 1: Initial Approach (Weeks 0-6)

• Provide patient education about fibromyalgia as a chronic condition with central sensitization 1, 2
• Begin aerobic and strengthening exercise program with gradual intensity increase 1, 2
• Add heated pool therapy if available 1, 2

Step 2: Insufficient Response (Weeks 6-12)

• Add cognitive behavioral therapy for patients with mood disorders or maladaptive coping 1, 2
• Consider acupuncture for pain reduction 1, 2
• Add meditative movement therapies or mindfulness-based stress reduction 1, 2

Step 3: Persistent Symptoms (Week 12+)

• Add first-line pharmacological therapy based on symptom profile: 1, 2
  • Amitriptyline for sleep disturbance and pain
  • Duloxetine for pain with depression/anxiety
  • Pregabalin for predominant pain without mood symptoms

Step 4: Partial Response

• If partial pain relief achieved, consider adding another first-line medication from a different class 1
• Multicomponent therapy (combining exercise, CBT, and medication) may provide greater benefit than any single intervention 1, 2

Step 5: No Response

• If no or inadequate pain relief at target dosage after adequate trial (8-12 weeks), switch to alternative first-line medication 1
• Consider second-line medications (milnacipran, tramadol, cyclobenzaprine) 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 1, 2
• Most treatments show modest effect sizes; expect 30-50% pain reduction rather than complete resolution 1, 2
• Long-term management requires ongoing exercise maintenance and periodic reassessment of medication need 2

Important Clinical Pitfalls

• Do not rely solely on pharmacological therapy without implementing exercise and behavioral approaches—exercise has the strongest evidence base 1, 2
• Do not escalate duloxetine beyond 60 mg/day or pregabalin beyond 450 mg/day—no additional benefit but increased adverse events 1, 4, 3
• Do not prescribe corticosteroids or strong opioids—they lack efficacy and cause harm 1, 2
• Do not expect complete pain resolution—the effect size for most treatments is relatively modest, with small to moderate benefits 5, 1
• Recognize that fibromyalgia represents abnormal central pain processing (central sensitization) rather than peripheral tissue damage, which explains why anti-inflammatory medications are ineffective 2