What is the recommended treatment approach for a patient with fibromyalgia?

Fibromyalgia Treatment

Begin immediately with aerobic and strengthening exercise as the primary intervention—this has the strongest evidence (Level Ia, Grade A) for improving pain, function, and quality of life, followed by pharmacological therapy only if exercise alone provides insufficient relief. 1, 2, 3

Step 1: Non-Pharmacological Management (First-Line)

Exercise Protocol (Mandatory Starting Point)

• Start with low-impact aerobic exercise (walking, swimming, cycling) at 20-30 minutes, 2-3 times weekly 1, 2, 3
• Gradually increase to 30-60 minutes, 5 days weekly over 4-8 weeks 2
• Add progressive resistance/strengthening training 2-3 times weekly once aerobic tolerance is established 2
• Heated pool therapy or hydrotherapy provides additional benefit and may improve exercise tolerance (Level IIa, Grade B) 1, 2

Additional Non-Pharmacological Options (Add if Needed After 4-6 Weeks)

• Cognitive behavioral therapy (CBT) for patients with depression, anxiety, or maladaptive coping strategies (Level Ia, Grade A) 1, 3
• Acupuncture for pain reduction (Level Ia, Grade A) 1, 3
• Meditative movement therapies (tai chi, yoga, qigong) for sleep disturbances and fatigue (Level Ia, Grade A) 1, 3
• Mindfulness-based stress reduction programs (Level Ia, Grade A) 1, 3

Step 2: Pharmacological Management (Second-Line, Add Only if Exercise Insufficient)

Choose ONE First-Line Medication Based on Symptom Profile:

For patients with prominent sleep disturbance:

• Amitriptyline 10 mg at bedtime, increase by 10 mg weekly to target 25-50 mg nightly (maximum 75 mg/day) 1, 2, 3
• Caution in elderly (≥65 years): Start at 10 mg due to anticholinergic effects (falls, confusion, constipation, urinary retention) 2

For patients with pain plus depression or anxiety:

• Duloxetine 30 mg daily for 1 week, then increase to 60 mg daily 1, 2, 3, 4
• Do NOT exceed 60 mg/day—no additional benefit but increased adverse events 1, 4

For patients with predominant pain without mood symptoms:

• Pregabalin 75 mg twice daily, titrate to 150 mg twice daily over 1 week 1, 2, 3, 5
• Target dose: 300-450 mg/day (150-225 mg twice daily) 1, 5
• Do NOT exceed 450 mg/day—no additional benefit but increased adverse events 1, 5
• Adjust dose for renal impairment (CrCl <60 mL/min) 1, 5

Alternative first-line option:

• Milnacipran 100-200 mg/day in divided doses, with dose escalation starting at lower doses over approximately 1 week 1

If Partial Response to First-Line Medication:

• Add tramadol (Level Ib, Grade A) when first-line medications are ineffective, though use with caution given opioid-related risks 1
• Consider switching to an alternative first-line medication from a different class rather than adding 1

Step 3: Critical Medications to AVOID

Never prescribe the following for fibromyalgia:

• Corticosteroids—no efficacy demonstrated (Level Ia, Grade A) 1, 2, 3
• Strong opioids (morphine, oxycodone, hydrocodone)—lack demonstrated benefit and carry significant risks (Level Ia, Grade A) 1, 2, 3
• NSAIDs as monotherapy—no evidence of benefit since fibromyalgia is not an inflammatory condition 1

Step 4: 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, 3
• Expect modest effect sizes: 30-50% pain reduction rather than complete resolution 1, 3
• Multicomponent therapy (combining exercise, CBT, and medication) may provide greater benefit than any single intervention 1, 3

Common Pitfalls to Avoid

• Starting with medication instead of exercise—exercise has the strongest evidence and should always be first-line 1, 2, 3
• Escalating duloxetine beyond 60 mg/day or pregabalin beyond 450 mg/day—no additional benefit but increased adverse events 1, 4, 5
• Using gabapentin with pregabalin—pharmacologically redundant as they bind to identical targets 1
• Inadequate patient education about fibromyalgia as a chronic condition with central sensitization—crucial for setting realistic expectations 1, 3