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

Non-Pharmacological Management (First-Line)

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 several weeks. 2
• Add progressive resistance training 2-3 times weekly once aerobic tolerance is established. 2
• 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
• Exercise should be individually tailored and gradually increased based on tolerance to avoid symptom flare-ups. 1

Cognitive Behavioral Therapy

• Cognitive behavioral therapy (CBT) is particularly beneficial for patients with concurrent mood disorders (depression, anxiety) or maladaptive coping strategies (Level Ia, Grade A). 1, 2
• CBT should be prioritized for patients with depression, anxiety, or unhelpful coping strategies, as it shows the strongest benefit in these subgroups. 2

Additional Non-Pharmacological Options

• Acupuncture is recommended for pain reduction with Level Ia, Grade A evidence. 2
• Meditative movement therapies (tai chi, yoga, qigong) can be helpful (Level Ia, Grade A), particularly for patients with prominent sleep disturbances and fatigue. 1, 2
• Mindfulness-based stress reduction programs are recommended. 2
• Multicomponent therapies that combine 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. 2, 3

First-Line Medications - Choose Based on Symptom Profile

Amitriptyline (Best for Sleep Disturbance + Pain)

• Start at 10 mg at bedtime, increase by 10 mg weekly to target 25-50 mg nightly (maximum 75 mg/day). 1, 2, 3
• Number needed to treat for 50% pain relief is 4.1, meaning approximately one in four patients achieves substantial benefit. 3
• Therapeutic effects typically emerge over 3-7 weeks. 3
• Monitor for anticholinergic effects (dry mouth, constipation, urinary retention) and morning sedation. 2, 3
• Level Ia, Grade A evidence for pain reduction and improved function. 1

Duloxetine (Best for Pain + Depression/Anxiety)

• Start at 30 mg once daily for 1 week, then increase to 60 mg once daily. 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
• Approximately 50% of patients achieve at least 30% pain reduction. 1
• Level Ia, Grade A evidence for pain reduction, functional improvement, and associated depression. 1

Pregabalin (Best for Predominant Pain Without Mood Symptoms)

• Start at 75 mg twice daily, increase to 150 mg twice daily over 1 week based on tolerance (maximum 450 mg/day). 1, 2, 3
• Do not escalate beyond 450 mg/day - no evidence of greater effect at 600 mg/day but increased dose-dependent adverse reactions. 1
• Patients receiving pregabalin are more likely to achieve 30% pain reduction (RR 1.38,95% CI 1.25 to 1.51). 1
• Requires dosage adjustment in patients with renal insufficiency. 1
• Level Ia, Grade A evidence; FDA-approved for fibromyalgia. 1

Milnacipran (Alternative SNRI)

• Recommended dosing is 100 mg/day or 200 mg/day given in divided doses, with dose escalation starting at lower doses and titrating up over approximately 1 week. 1, 4
• Similar efficacy to duloxetine for pain reduction (RR 1.38,95% CI 1.25 to 1.51) and provides small but significant benefits on fatigue (SMD −0.14) and disability (SMD −0.16). 1
• Treatment with 200 mg/day does not confer greater benefit than 100 mg/day. 4
• Level Ia, Grade A evidence. 1

Second-Line Medication

Tramadol (When First-Line Medications Are Ineffective)

• Recommended for pain management (Level Ib, Grade A) when other medications are ineffective. 1
• Should be used cautiously due to opioid-related risks. 1

Medications to AVOID - Critical Pitfalls

Corticosteroids have no role in fibromyalgia treatment and are not recommended. 1, 2, 3

Strong opioids (morphine, oxycodone, hydrocodone) are not recommended as they lack demonstrated benefit and carry significant risks including addiction, tolerance, and worsening of central sensitization. 1, 2, 3

NSAIDs (ibuprofen, naproxen) should not be used as monotherapy - no evidence of improved outcome compared with placebo since fibromyalgia is not an inflammatory condition. 1, 2

Treatment Algorithm

Weeks 0-4

• Begin patient education about fibromyalgia as a condition of central sensitization (abnormal pain processing) rather than peripheral tissue damage. 2, 3
• Start aerobic and strengthening exercise program immediately. 2
• Add heated pool therapy if available and patient tolerates. 1, 2

Weeks 4-8 (If Insufficient Response)

• Add cognitive behavioral therapy for patients with depression, anxiety, or maladaptive coping strategies. 2
• Consider adding acupuncture, meditative movement therapies, or mindfulness-based stress reduction. 2

Weeks 8-12 (If Still Insufficient Response)

• Add first-line pharmacological therapy based on symptom profile:
  • Amitriptyline for prominent sleep disturbance and pain 2, 3
  • Duloxetine for pain plus depression or anxiety 2, 3
  • Pregabalin for predominant pain without mood symptoms 2, 3

Ongoing Management

• 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. 2
• If partial pain relief is achieved with one medication, consider adding another first-line medication from a different class. 1
• If no or inadequate pain relief occurs at target dosage after an adequate trial, switch to an alternative first-line medication. 1
• Multicomponent therapy (combining exercise, CBT, and medication) may provide greater benefit than any single intervention. 1, 2

Important Clinical Considerations

• Fibromyalgia represents abnormal central pain processing (central sensitization) rather than peripheral tissue damage or inflammation. 2, 3
• Normal laboratory results support rather than exclude the diagnosis. 3
• The effect size for most treatments is relatively modest, with most showing small to moderate benefits. 1
• Long-term management requires ongoing exercise maintenance and periodic reassessment of medication need. 2
• Dropout rates due to medication side effects are approximately double compared to placebo, though there is no difference in serious adverse events. 1