What is the treatment approach for a patient with fibromyalgia?

Treatment for Fibromyalgia

First-Line Treatment: Exercise (Mandatory Starting Point)

Exercise is the only therapy with a "strong for" recommendation and must be initiated immediately as the foundation of fibromyalgia treatment. 1, 2

• Start with low-impact aerobic exercise (walking, swimming, cycling) at 20-30 minutes, 2-3 times weekly 2, 3
• Gradually increase over 4-8 weeks to 30-60 minutes, 5 days weekly 2, 3
• Add progressive resistance/strengthening training 2-3 times weekly once aerobic tolerance is established 2, 3
• Heated pool therapy or hydrotherapy provides additional benefit and improves exercise tolerance (Level IIa, Grade B) 2, 3

All other therapies, including medications, are "weak for" recommendations and should only be added if exercise alone provides insufficient relief after 4-6 weeks. 1, 2

Second-Line: Additional Non-Pharmacological Therapies

If exercise alone is insufficient after 4-6 weeks, add these based on predominant symptoms:

For Mood Disorders or Maladaptive Coping

• Cognitive behavioral therapy (CBT) for patients with depression, anxiety, or unhelpful coping strategies (Level Ia, Grade A) 1, 2, 3

For Additional Pain Relief

• Acupuncture (Level Ia, Grade A) 2, 3
• Meditative movement therapies: tai chi, yoga, or qigong (Level Ia, Grade A) 2, 3
• Mindfulness-based stress reduction (Level Ia, Grade A) 2, 3

Third-Line: Pharmacological Therapy

Add medication only if non-pharmacological approaches provide inadequate relief. Choose ONE first-line medication based on the patient's symptom profile:

For Prominent Sleep Disturbance + Pain

• Amitriptyline 10 mg at bedtime, increase by 10 mg weekly to target 25-50 mg nightly (Level Ia, Grade A) 2, 3, 4
• Number needed to treat for 50% pain relief: 4.1 2
• CAUTION in patients ≥65 years: Start at 10 mg and titrate slowly due to anticholinergic effects (falls, confusion, constipation, urinary retention) 2, 4

For Pain + Depression or Anxiety

• Duloxetine 30 mg daily for 1 week, then increase to 60 mg daily (Level Ia, Grade A) 2, 3, 4, 5
• Approximately 50% of patients achieve at least 30% pain reduction 2, 5
• Do NOT escalate beyond 60 mg/day—no additional benefit but increased adverse events 2, 5

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) 2, 3, 4
• Target dose range: 300-450 mg/day 2
• Do NOT exceed 450 mg/day—no additional benefit but increased dose-dependent adverse reactions 2
• Requires dose adjustment for creatinine clearance <60 mL/min 2, 4

Alternative First-Line Option

• Milnacipran 100-200 mg/day in divided doses (Level Ia, Grade A) 2
• Similar efficacy to duloxetine for pain reduction (RR 1.38,95% CI 1.25 to 1.51) 2
• Provides small but significant benefits on fatigue (SMD -0.14) and disability (SMD -0.16) 2

Fourth-Line: Second-Line Medications (If First-Line Fails)

Cyclobenzaprine

• Improves sleep but not pain (SMD 0.34 at 12 weeks) 1
• 85% experience side effects; only 71% complete studies 1
• Weak for recommendation (75% agreement) 1

Tramadol

• Consider only when first-line medications are ineffective (Level Ib, Grade A) 2, 3
• Use with caution given opioid-related risks 2, 3

Critical Medications to AVOID

These medications have NO role in fibromyalgia treatment:

• Corticosteroids: No efficacy demonstrated (Level Ia, Grade A) 2, 3, 4
• Strong opioids (morphine, oxycodone, hydrocodone): Lack demonstrated benefit and carry significant risks (Level Ia, Grade A) 2, 3, 4
• NSAIDs as monotherapy: No evidence of improved outcome compared with placebo 2

Monitoring and Reassessment Algorithm

• Evaluate treatment response every 4-8 weeks using pain scores (0-10 scale), functional status, and patient global impression of change 2, 3, 4
• Expect 30-50% pain reduction rather than complete resolution—most treatments show modest effect sizes 1, 3
• If partial pain relief at target dosage after adequate trial: Add another first-line medication from different class 2
• If no or inadequate pain relief at target dosage after adequate trial: Switch to alternative first-line medication 2
• Multicomponent therapy (combining exercise, CBT, and medication) may provide greater benefit than any single intervention 2, 3, 4

Common Pitfalls to Avoid

• Starting with medication instead of exercise: Exercise has the strongest evidence and must be the foundation 1, 2, 3
• Escalating duloxetine beyond 60 mg/day or pregabalin beyond 450 mg/day: No additional benefit but increased adverse events 2, 5
• Prescribing strong opioids or corticosteroids: These lack efficacy and cause harm 2, 3, 4
• Relying solely on pharmacological therapy: Non-pharmacological approaches, particularly exercise, are essential 1, 2, 3
• Not providing patient education: Understanding fibromyalgia as a chronic condition with central sensitization is crucial for setting realistic expectations 2, 3
• Forgetting renal dose adjustment for pregabalin: Required for creatinine clearance <60 mL/min 2, 4