What are the treatment options for a patient with fibromyalgia?

Fibromyalgia Treatment

Begin immediately with aerobic and strengthening exercise as your primary intervention—this has the strongest evidence (Level Ia, Grade A) for improving pain, function, and quality of life in fibromyalgia patients. 1, 2

Initial Non-Pharmacological Approach (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
• Heated pool therapy or hydrotherapy provides additional benefit and may improve exercise tolerance (Level IIa, Grade B) 1, 2
• All forms of exercise improve pain (effect size -0.72 to -0.96) and depression (effect size -0.35 to -1.22) except flexibility exercise alone 3

Additional Non-Pharmacological Therapies

• Cognitive behavioral therapy (CBT) is recommended for patients with depression, anxiety, or maladaptive coping strategies (Level Ia, Grade A), improving pain, sleep, and depression (effect size -0.35 to -0.55) 1, 2, 3
• Acupuncture reduces pain (Level Ia, Grade A) 1, 2
• Meditative movement therapies (tai chi, yoga, qigong) improve sleep disturbances (effect size -0.61) and fatigue (effect size -0.66) 1, 2
• Mindfulness-based stress reduction programs are recommended (Level Ia, Grade A) 1, 2

Pharmacological Therapy (Second-Line)

Add pharmacological therapy only after initiating exercise and if non-pharmacological approaches provide insufficient relief after 4-6 weeks. 1

First-Line Medications

Choose based on predominant symptom:

• For 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; NNT for 50% pain relief = 4.1) 1, 2

• For 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

  • Do NOT escalate beyond 60 mg/day—no additional benefit but increased adverse events 1
  • Approximately 50% of patients achieve at least 30% pain reduction 1

• For 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 300-450 mg/day; do NOT exceed 450 mg/day—no additional benefit but increased adverse effects 1, 5
  • Adjust dose for creatinine clearance <60 mL/min 1

• Alternative: Milnacipran 100-200 mg/day in divided doses (Level Ia, Grade A), with dose escalation over approximately 1 week 1

Second-Line Medication

• Tramadol (Level Ib, Grade A) only when first-line medications are ineffective, used with caution given opioid-related risks 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—they lack demonstrated benefit and carry significant risks 1, 2, 6
• NSAIDs (ibuprofen, naproxen) have limited to no benefit as monotherapy since fibromyalgia is not an inflammatory condition 1, 2, 6

Treatment Algorithm

1. Week 0: Initiate aerobic and strengthening exercise immediately 2
2. Week 4-6: If insufficient response, add CBT, heated pool therapy, or acupuncture 1
3. Week 4-6: If still inadequate relief, add ONE first-line medication based on predominant symptom 2
4. Week 8-12: If partial response, consider adding a second first-line medication from a different class 1
5. Week 12+: If no response, switch to alternative first-line medication 1

Monitoring and Reassessment

• 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—most treatments show modest effect sizes 1, 2
• Multicomponent therapy (combining exercise, CBT, and medication) provides greater benefit than any single intervention 1, 2, 3

Important Caveats

• Exercise must be gradually increased to avoid symptom flare-ups—start low and go slow 1
• Amitriptyline should be used with caution in older adults (≥65 years) due to anticholinergic effects 1
• Gabapentin and pregabalin should NOT be combined—they bind to identical targets with the same mechanism, making this combination pharmacologically redundant 1
• Long-term management requires ongoing exercise maintenance and periodic reassessment of medication need 2