What are the treatment options for fibromyalgia?

Treatment of 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, then add pharmacological therapy only if exercise alone provides insufficient relief after 4-6 weeks. 1, 2

Initial Non-Pharmacological Management (First-Line)

Exercise is the cornerstone of fibromyalgia treatment and should be initiated before considering medications. 1, 2

Exercise Protocol

• Start with 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 exercise is tolerated. 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 exercises (tai chi, yoga, qigong) and strengthening exercises specifically improve fatigue (effect size -0.77 to -1.00). 3
• Aerobic and strengthening exercises specifically improve sleep (effect size -0.74 to -1.33). 3

Additional Non-Pharmacological Therapies

• Heated pool therapy or hydrotherapy provides additional benefit and may improve exercise tolerance (Level IIa, Grade B). 1, 2
• Cognitive behavioral therapy (CBT) improves pain, sleep, and depression (effect size -0.35 to -0.55) and is particularly beneficial for patients with depression, anxiety, or maladaptive coping strategies (Level Ia, Grade A). 1, 3
• Acupuncture reduces pain and improves quality of life (Level Ia, Grade A). 1, 2, 4
• Mindfulness-based stress reduction and meditative movement therapies (tai chi, yoga, qigong) improve multiple symptoms (Level Ia, Grade A). 1, 2

Pharmacological Management (Second-Line)

Add pharmacological therapy only after 4-6 weeks of exercise if pain reduction is less than 30% or functional improvement is inadequate. 1, 2

First-Line Medications (All Level Ia, Grade A Evidence)

Choose based on predominant symptom profile:

For Patients with Prominent Sleep Disturbance and Pain:

• Amitriptyline 10-25 mg at bedtime, titrate by 10-25 mg weekly to 50-75 mg as tolerated (number needed to treat for 50% pain relief is 4.1). 1, 2

For Patients with Pain Plus Depression or Anxiety:

• Duloxetine 30 mg daily for 1 week, then increase to 60 mg daily. 1, 2, 5
• Do NOT escalate duloxetine beyond 60 mg/day—no additional benefit but increased adverse events. 1, 5
• Approximately 50% of patients achieve at least 30% pain reduction with duloxetine 60 mg/day. 5

For Patients with Predominant Pain Without Mood Symptoms:

• Pregabalin 75 mg twice daily, titrate to 150 mg twice daily (300 mg/day total) over 1 week, may increase to 225 mg twice daily (450 mg/day total) if needed. 1, 2, 6
• Do NOT escalate pregabalin beyond 450 mg/day—no additional benefit but increased dose-dependent adverse reactions. 1, 6
• Patients receiving pregabalin are more likely to achieve 30% pain reduction (RR 1.38,95% CI 1.25 to 1.51). 1

Alternative First-Line Option:

• Milnacipran 100-200 mg/day in divided doses (titrate from lower doses over approximately 1 week) for pain reduction and fatigue symptoms. 1

Second-Line Medication (When First-Line Medications Ineffective):

• Tramadol for pain management (Level Ib, Grade A) when other medications are ineffective. 1

Critical Medications to AVOID

These 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

Week 0-6: Initial Phase

1. Provide patient education about fibromyalgia as a chronic condition with central sensitization (abnormal pain processing). 2
2. Initiate low-impact aerobic exercise 20-30 minutes, 2-3 times weekly. 2
3. Add heated pool therapy if available. 1, 2

Week 6-12: Escalation Phase (If <30% Pain Reduction)

1. Increase exercise to 30-60 minutes, 5 days weekly. 2
2. Add progressive resistance training 2-3 times weekly. 2
3. Add CBT if depression, anxiety, or maladaptive coping present. 1, 3
4. Consider adding acupuncture or mindfulness-based stress reduction. 1, 2
5. Initiate first-line medication based on symptom profile (amitriptyline, duloxetine, or pregabalin). 1, 2

Week 12+: Maintenance and Reassessment

1. Evaluate treatment response every 4-8 weeks using pain scores (0-10 scale), functional status, and patient global impression of change. 1, 2
2. If partial response (30-50% pain reduction), consider adding another first-line medication from a different class. 1
3. If no response at target dosage after adequate trial, switch to alternative first-line medication. 1
4. Multicomponent therapy (combining exercise, CBT, and medication) may provide greater benefit than any single intervention. 1, 2, 7

Expected Outcomes and Realistic Expectations

Most treatments show modest effect sizes; expect 30-50% pain reduction rather than complete resolution. 8, 2

The effect size for many treatments is relatively modest, with most showing small to moderate benefits. 8

Common Pitfalls to Avoid

• Relying solely on pharmacological therapy without implementing exercise and behavioral approaches. 2
• Not providing adequate patient education about the chronic nature of fibromyalgia and central sensitization. 2
• Escalating duloxetine beyond 60 mg/day or pregabalin beyond 450 mg/day—no additional benefit but increased adverse events. 1, 5, 6
• Prescribing corticosteroids, strong opioids, or NSAIDs as monotherapy. 1, 2
• Failing to reassess treatment efficacy regularly (every 4-8 weeks). 1, 2