What are the treatment options for fibromyalgia?

Treatment Options for Fibromyalgia

Exercise is the only treatment with a "strong for" recommendation and should be initiated immediately as first-line therapy, with pharmacological interventions reserved for patients who fail to respond adequately to non-pharmacological approaches. 1, 2

Initial Management: Non-Pharmacological Therapies (First-Line)

Exercise (Strongest Evidence)

• Start aerobic exercise immediately at 20-30 minutes, 2-3 times weekly, gradually increasing to 30-60 minutes, 5 days weekly 3
• Add progressive resistance training 2-3 times weekly after establishing aerobic exercise tolerance 3
• Low-impact options include walking, swimming, or cycling 3
• Heated pool therapy or hydrotherapy provides additional benefit and may improve exercise tolerance 2, 3
• Exercise has Level Ia, Grade A evidence with 100% expert agreement—the only "strong for" recommendation in fibromyalgia management 1, 2

Additional Non-Pharmacological Therapies

• Cognitive behavioral therapy (CBT) is recommended specifically for patients with concurrent depression, anxiety, or maladaptive coping strategies 2, 3
• Acupuncture provides pain reduction with Level Ia, Grade A evidence 2, 3
• Meditative movement therapies (tai chi, yoga, qigong) improve sleep disturbances and fatigue 2, 3
• Mindfulness-based stress reduction programs are beneficial 2, 3

Pharmacological Management (Second-Line)

When to Initiate Medications

• Add pharmacotherapy only after 4-6 weeks of non-pharmacological therapy if response is insufficient 2
• Medications should target specific problematic symptoms: severe pain, sleep disturbance, or mood disorders 1

First-Line Medications (All "Weak For" Recommendations)

Amitriptyline:

• Start 10-25 mg at bedtime for patients with prominent sleep disturbance and pain 3
• Titrate by 10-25 mg weekly to 50-75 mg as tolerated (maximum 75 mg/day) 2, 3
• Number needed to treat for 50% pain relief is 4.1 2
• Level Ia, Grade A evidence 2

Duloxetine:

• Start 30 mg daily for 1 week, then increase to 60 mg daily 3
• Recommended for patients with pain plus depression or anxiety 3
• Do not escalate beyond 60 mg/day—no additional benefit but increased adverse events 2
• Approximately 50% of patients achieve at least 30% pain reduction 2
• Level Ia, Grade A evidence 2

Pregabalin:

• Start 75 mg twice daily, titrate to 150 mg twice daily over 1 week 3, 4
• Recommended for patients with predominant pain without mood symptoms 3
• Maximum effective dose is 450 mg/day—do not exceed this as 600 mg/day shows no additional benefit but increased dose-dependent adverse reactions 2, 4
• Requires dosage adjustment in renal insufficiency 2
• FDA-approved for fibromyalgia 2, 4
• Level Ia, Grade A evidence 2

Milnacipran:

• Dose escalation starting at lower doses, titrating up over approximately 1 week to minimize side effects 2
• Target maintenance dose 100-200 mg/day in divided doses 2
• Similar efficacy to duloxetine for pain reduction (RR 1.38,95% CI 1.25 to 1.51) 2
• Dropout rates due to side effects are approximately double compared to placebo 2
• Level Ia, Grade A evidence 2

Second-Line Medications

Cyclobenzaprine:

• 85% of patients experience side effects with only 71% completing studies 1
• Improves sleep (SMD 0.34) but not pain significantly 1
• Number needed to treat is 4.8 (95% CI 3.0 to 11.0) 1
• "Weak for" recommendation with 75% expert agreement 1

Tramadol:

• Reserved for pain management when other medications are ineffective 2
• Level Ib, Grade A evidence 2

Medications to Avoid

Strong opioids (morphine, oxycodone, hydrocodone):

• Not recommended—lack demonstrated benefit and carry significant risks 2, 3, 5

Corticosteroids:

• No role in fibromyalgia treatment due to lack of efficacy 2, 3

NSAIDs as monotherapy:

• No evidence of improved outcome compared with placebo since fibromyalgia is not an inflammatory condition 2, 3

Treatment Algorithm

1. Week 0: Begin patient education about fibromyalgia as a chronic condition with central sensitization and initiate aerobic exercise program 1, 3

2. Weeks 1-6: Gradually increase exercise intensity and add heated pool therapy or other non-pharmacological therapies as tolerated 2, 3

3. Week 4-8: If insufficient response, add CBT for mood disorders or acupuncture 2, 3

4. Week 6-8: If still insufficient response, add first-line medication tailored to predominant symptoms:

   • Amitriptyline for sleep disturbance 3
   • Duloxetine for pain with depression/anxiety 3
   • Pregabalin for pain without mood symptoms 3

5. Week 12-16: If partial response, consider adding another first-line medication from a different class 2

6. Week 16+: If no response at target dosage, switch to alternative first-line medication 2

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, 3
• Most treatments show modest effect sizes—expect 30-50% pain reduction rather than complete resolution 1, 3
• Multicomponent therapy (combining exercise, CBT, and medication) may provide greater benefit than any single intervention 2, 3

Critical Pitfalls to Avoid

• Do not rely solely on pharmacological therapy without implementing exercise—exercise is the only "strong for" recommendation 1, 2
• Do not escalate duloxetine beyond 60 mg/day or pregabalin beyond 450 mg/day—no additional benefit but increased adverse events 2, 4
• Do not prescribe strong opioids—they lack benefit and cause significant harm 2, 3
• Do not use NSAIDs as monotherapy—fibromyalgia involves central pain processing, not peripheral inflammation 2, 3
• Do not skip patient education—understanding the chronic nature of fibromyalgia with central sensitization is crucial for setting realistic expectations 1, 3