What are the treatment options for fibromyalgia?

Treatment 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

Non-Pharmacological Management (First-Line Treatment)

Exercise Program - Start Here

• Initiate low-impact aerobic exercise (walking, swimming, cycling) at 20-30 minutes, 2-3 times weekly, gradually increasing to 30-60 minutes, 5 days weekly over 4-8 weeks. 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, particularly for patients who struggle with land-based exercise. 1, 2

Additional Non-Pharmacological Therapies

• Cognitive behavioral therapy (CBT) is recommended (Level Ia, Grade A) particularly for patients with depression, anxiety, or maladaptive coping strategies. 1, 2
• Acupuncture provides pain reduction with Level Ia, Grade A evidence. 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. 2
• Multicomponent therapies that combine different approaches show significant benefit for overall symptom management. 1

Pharmacological Management (Second-Line Treatment)

When to Add Medications

• Add pharmacological therapy if insufficient response after 4-6 weeks of non-pharmacological interventions, or if symptoms are severe enough to prevent participation in exercise programs. 1

First-Line Medications - Choose Based on 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 (Level Ia, Grade A). 1, 2
• The number needed to treat for 50% pain relief is 4.1. 1
• Maximum effective dose is 75 mg/day; higher doses do not provide additional benefit. 1

For patients with pain plus depression or anxiety:

• Duloxetine 30 mg daily for 1 week, then increase to 60 mg daily (Level Ia, Grade A). 1, 2
• Do not escalate beyond 60 mg/day as doses above 60 mg do not provide additional benefit but increase adverse events. 1, 3
• Approximately 50% of patients achieve at least 30% pain reduction. 1, 3

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 (Level Ia, Grade A). 1, 2
• May increase to 225 mg twice daily (450 mg/day total) if needed after 1 week. 1, 4
• Do not exceed 450 mg/day as 600 mg/day shows no additional benefit but increased dose-dependent adverse reactions. 1, 4

Alternative first-line option:

• Milnacipran 100-200 mg/day in divided doses, with dose escalation starting at lower doses and titrating up over approximately 1 week. 1

Second-Line Medication

• Tramadol (Level Ib, Grade A) for pain management when first-line medications are ineffective or not tolerated. 1

Treatment Algorithm

Week 0-6:

• Begin aerobic exercise 20-30 minutes, 2-3 times weekly. 2
• Add heated pool therapy if available and patient has difficulty with land-based exercise. 1, 2
• Provide patient education about fibromyalgia as a chronic condition with central sensitization. 1

Week 4-6 Assessment:

• If insufficient response (less than 30% pain reduction), add CBT for patients with mood disorders or add acupuncture/mindfulness-based stress reduction. 1, 2
• Consider adding first-line medication based on symptom profile (amitriptyline for sleep disturbance, duloxetine for depression/anxiety, pregabalin for predominant pain). 1, 2

Week 8-12 Assessment:

• Evaluate treatment response using pain scores (0-10 scale), functional status, and patient global impression of change. 1, 2
• If partial pain relief (30-50% reduction) is achieved with medication, continue current regimen and optimize exercise program. 1
• If inadequate pain relief (less than 30% reduction) at target dosage, switch to an alternative first-line medication from a different class. 1
• If partial pain relief but still significant symptoms, consider adding another first-line medication from a different class. 1

Ongoing Management:

• Reassess every 4-8 weeks using pain scores, functional status, and patient global impression of change. 1, 2
• Expect 30-50% pain reduction rather than complete resolution; most treatments show modest effect sizes. 1, 2
• Maintain exercise program long-term as the cornerstone of management. 2

Critical Medications to Avoid

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

Common Pitfalls to Avoid

• Do not rely solely on pharmacological therapy without implementing exercise and behavioral approaches. 1
• Do not start exercise too aggressively; gradual progression is essential to prevent symptom flare-ups and treatment abandonment. 1
• Do not escalate duloxetine beyond 60 mg/day or pregabalin beyond 450 mg/day as this provides no additional benefit but increases adverse events. 1, 4, 3, 4
• Do not fail to provide adequate patient education about the chronic nature of fibromyalgia and realistic expectations for treatment outcomes. 1, 2
• Do not expect monotherapy to adequately address all symptoms; multicomponent therapy combining exercise, CBT, and medication may provide greater benefit than any single intervention. 1, 2