What are the treatment options for fibromyalgia?

Treatment Options 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

Initial Non-Pharmacological Management (First-Line)

Exercise Protocol

• 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 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 1, 2

Additional Non-Pharmacological Therapies

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

Important caveat: While exercise has the strongest evidence, most treatments show modest effect sizes with 30-50% pain reduction rather than complete resolution. 2 The combination of non-pharmacological and pharmacological approaches may be more effective than either alone. 3, 1

Pharmacological Management (Second-Line)

First-Line Medications

Add pharmacological therapy only if non-pharmacological interventions provide insufficient relief after 4-6 weeks. 1

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
• Number needed to treat for 50% pain relief is 4.1 1
• Caution in older adults (≥65 years) due to anticholinergic effects 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, 4
• Doses above 60 mg/day do not provide additional benefit but increase adverse events 1, 4
• Approximately 50% of patients achieve at least 30% pain reduction 1

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, 5
• Target dose range is 300-450 mg/day 1, 5
• Doses above 450 mg/day offer no additional benefit but increased adverse effects 1, 5
• Requires dose adjustment in patients with creatinine clearance <60 mL/min 1

Alternative First-Line Option:

• Milnacipran 100-200 mg/day in divided doses (Level Ia, Grade A) 1
• Dose escalation starting at lower doses and titrating up over approximately 1 week to minimize side effects 1

Second-Line Medications

• Cyclobenzaprine can be considered for pain management (Level Ia, Grade A) 1
• Tramadol is recommended for pain management (Level Ib, Grade A) when first-line medications are ineffective 1, 2
• Use tramadol with caution given opioid-related risks 1, 2

Medications to Avoid

Critical pitfalls 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 2

Treatment Algorithm

Step 1: Initial Approach (Weeks 0-6)

• Begin with patient education about fibromyalgia as a chronic condition with central sensitization 3, 2
• Start aerobic and strengthening exercise program immediately 1, 2
• Add heated pool therapy if available 1, 2

Step 2: If Insufficient Response After 4-6 Weeks

• Add cognitive behavioral therapy for patients with mood disorders or maladaptive coping 1, 2
• Consider acupuncture for pain reduction 1, 2
• Add meditative movement therapies or mindfulness-based stress reduction 1, 2

Step 3: If Still Insufficient Response

• Add first-line pharmacological therapy based on symptom profile:
  • Sleep disturbance predominant → Amitriptyline 1, 2
  • Depression/anxiety present → Duloxetine 1, 2, 4
  • Pure pain without mood symptoms → Pregabalin 1, 2, 5

Step 4: Reassessment and Adjustment

• Evaluate treatment response every 4-8 weeks using pain scores (0-10 scale), functional status, and patient global impression of change 1, 2
• If partial pain relief is achieved, 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
• Consider tramadol only when first-line medications are ineffective 1, 2

Evidence Quality and Nuances

The 2017 EULAR guidelines represent a significant advancement, moving from recommendations based predominantly on expert opinion to ones firmly based on scientific evidence from high-quality reviews and meta-analyses. 3 However, the size of effect for many treatments is relatively modest. 3 Exercise maintains a "strong for" designation with 100% expert agreement, while most pharmacological treatments have "weak for" recommendations despite Level Ia evidence. 1, 6

Multicomponent therapy (combining exercise, CBT, and medication) may provide greater benefit than any single intervention, though more research is needed. 3, 1, 2 Long-term management requires ongoing exercise maintenance and periodic reassessment of medication need. 2