Fibromyalgia: Symptoms and Treatment
Fibromyalgia presents with chronic widespread pain lasting ≥3 months as the dominant symptom, accompanied by multiple tender points on examination, and you should treat with exercise as first-line therapy, adding duloxetine or pregabalin for severe pain or sleep disturbance. 1
Core Clinical Symptoms
Primary manifestations:
- Generalized, widespread chronic pain (≥3 months duration) with multiple tender points upon physical examination 1
- Reduced pain threshold with hyperalgesia (increased pain response) and allodynia (pain from normally non-painful stimuli) 1
- Fatigue that significantly impacts daily function 1
- Non-refreshed sleep and sleep disturbances 1
Associated symptoms:
- Cognitive dysfunction ("fibro fog") 1, 2
- Mood disturbances including depression and anxiety 1
- Headache and migraine 1
- Variable bowel habits and diffuse abdominal pain 1
- Urinary frequency 1
The underlying mechanism involves central sensitization—inadequate filtering of nociceptive signals by descending antinociceptive pathways, resulting in disordered pain processing rather than peripheral tissue damage 1, 2.
Treatment Algorithm
Stage 1: Initial Management (All Patients)
Begin with patient education and non-pharmacological therapies 1:
- Exercise therapy (aerobic, aquatic, and/or resistance) is the only "strong for" recommendation based on meta-analyses and should be initiated immediately 1, 3
- Patient education about the condition, emphasizing that symptoms are real despite absence of tissue damage 1, 3
- Cognitive behavioral therapy if available 1
Stage 2: Pharmacological Intervention for Non-Responders
For severe pain or sleep disturbance, add FDA-approved medications with strongest evidence 1:
First-line pharmacological options:
Pregabalin 300-450 mg/day (FDA-approved; strongest evidence among medications) 1, 4
Milnacipran (FDA-approved) 1
Second-line options for off-label use:
- Amitriptyline (tricyclic antidepressant) 2
- Cyclobenzaprine (muscle relaxant) 1
- Gabapentin 2
- Tramadol (opioid) 1
Stage 3: Psychological Therapies
For mood disorders and unhelpful coping strategies 1:
- Cognitive behavioral therapy specifically targeting pain catastrophizing and maladaptive coping 1, 3
- Address comorbid depression and anxiety, which are frequently associated with chronic pain 1
Stage 4: Multimodal Rehabilitation
For severe disability not responding to above measures 1:
- Combine exercise therapy with psychological interventions 1
- Consider multidisciplinary biopsychosocial rehabilitation programs 1
Critical Pitfalls to Avoid
Do not prescribe NSAIDs or opioids as primary therapy 2:
- NSAIDs have not demonstrated benefits for fibromyalgia 2
- Opioids are second-line treatments at best, with limited evidence for long-term effectiveness and significant risks of addiction and overdose 1
- Opioid-related deaths (16,651 in 2010) vastly exceed those from acetaminophen (881) or NSAIDs (228) 1
Recognize that monotherapy is usually insufficient 6, 7:
- The application of only pharmacological or only non-pharmacological treatment is most often unsuccessful 6
- Combination therapy addressing multiple symptom domains is most effective 3, 7
Avoid up-titrating duloxetine beyond 60 mg in non-responders 5:
- Patients who don't respond to 60 mg are unlikely to benefit from 120 mg 5
- Higher doses increase adverse reactions and discontinuations 5
Special Considerations for Women Age 30-60
This demographic represents the highest-risk population, as fibromyalgia is diagnosed more frequently in women and prevalence increases with age 7, 2. Screen for comorbid conditions including functional somatic syndromes, psychiatric diagnoses, and rheumatologic conditions 2. The Fibromyalgia Rapid Screening Tool can facilitate early diagnosis 2.