What are the management options for fibromyalgia?

Management 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 in fibromyalgia patients. 1, 2

Non-Pharmacological Management (First-Line Treatment)

Exercise Therapy - The Foundation

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

Psychological and Mind-Body Interventions

• Cognitive behavioral therapy (CBT) is recommended for patients with depression, anxiety, or maladaptive coping strategies (Level Ia, Grade A). 1, 2
• Acupuncture is recommended for pain reduction with Level Ia, Grade A evidence. 1, 2
• Meditative movement therapies including tai chi, yoga, or qigong are recommended with Level Ia, Grade A evidence. 1, 2
• Mindfulness-based stress reduction programs are recommended with Level Ia, Grade A evidence. 1, 2

Pharmacological Management (Second-Line Treatment)

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

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, 3
• Do not escalate beyond 60 mg/day as doses above 60 mg/day provide no additional benefit but increase adverse events. 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, 4
• Patients who do not experience sufficient benefit with 300 mg/day may be increased to 225 mg twice daily (450 mg/day). 4
• Do not exceed 450 mg/day as there is no evidence that 600 mg/day confers additional benefit, but this dose is less well tolerated. 1, 4

Second-Line Medication

• Tramadol is recommended for pain management (Level Ib, Grade A) when first-line medications are ineffective. 1

Alternative SNRI Option

• Milnacipran 100-200 mg/day in divided doses is an alternative SNRI with similar efficacy to duloxetine for pain reduction and provides small but significant benefits on fatigue and disability. 1

Treatment Algorithm

Week 0-1:

• Initiate patient education about fibromyalgia as a chronic condition with central sensitization. 2
• Begin low-impact aerobic exercise 20-30 minutes, 2-3 times weekly. 2

Week 2-4:

• Increase exercise frequency toward 30-60 minutes, 5 days weekly. 2
• Add heated pool therapy if available. 1, 2

Week 4-6 (if insufficient response):

• Add cognitive behavioral therapy for patients with mood disorders or maladaptive coping. 1, 2
• Consider adding acupuncture or meditative movement therapies. 1, 2

Week 6-8 (if still insufficient response):

• Add pharmacological therapy based on symptom profile:
  • Amitriptyline for sleep disturbance 2
  • Duloxetine for comorbid depression/anxiety 2
  • Pregabalin for predominant pain 2

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
• Expect 30-50% pain reduction rather than complete resolution, as most treatments show modest effect sizes. 1, 2
• Multicomponent therapy (combining exercise, CBT, and medication) may provide greater benefit than any single intervention. 1, 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 (Level Ia, Grade A). 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, as non-pharmacological interventions have the strongest evidence. 1, 2
• Do not escalate duloxetine beyond 60 mg/day or pregabalin beyond 450 mg/day, as higher doses provide no additional benefit but increase adverse events. 1, 4, 3
• Do not expect complete pain resolution; set realistic expectations of 30-50% pain reduction. 2
• Exercise must be started gradually to avoid symptom flare-ups that lead to treatment abandonment. 1