Fibromyalgia Treatment
First-Line Recommendation: Start with Exercise
Begin immediately with a graduated aerobic and strengthening exercise program, as this has the strongest evidence (Level Ia, Grade A) for improving pain, function, and quality of life in fibromyalgia. 1
Exercise Implementation Protocol
- Week 1-2: Start with 10-15 minutes of low-intensity aerobic activity (walking, swimming, or cycling) 2-3 times weekly 1
- Week 3-6: Gradually increase duration to 20-30 minutes per session, 3-5 times weekly 1
- Ongoing: Add resistance training 2-3 times weekly targeting major muscle groups once aerobic tolerance is established 1
The effect size for exercise on pain is approximately 0.65-0.96, with similar benefits for physical function (0.66) and quality of life 2. This exceeds the modest benefits seen with any single medication 3.
Adjunctive Non-Pharmacological Options
- Heated pool therapy (with or without exercise): 25-90 minute sessions, 2-3 times weekly for 5-24 weeks (Level IIa, Grade B evidence) 1
- Cognitive behavioral therapy: Particularly beneficial when mood disorders or maladaptive coping strategies are present (Level Ia, Grade A evidence) 1
- Multicomponent therapy: Combining exercise, CBT, and other modalities shows superior outcomes to single interventions 1
Second-Line: Add Pharmacotherapy After 4-6 Weeks
If exercise and non-pharmacological interventions provide insufficient relief after 4-6 weeks, add one of three first-line medications: duloxetine 60 mg daily, pregabalin 300-450 mg daily, or amitriptyline 25-50 mg nightly. 1, 4
Medication Selection Algorithm
Choose duloxetine (60 mg once daily) when:
- Comorbid depression is present 1
- Patient prefers once-daily dosing 5
- Anticholinergic side effects are a concern 4
Start at 30 mg daily for 1 week, then increase to 60 mg daily 5. Do not exceed 60 mg daily—higher doses provide no additional benefit but increase adverse events 1, 5.
Choose pregabalin (300-450 mg daily in divided doses) when:
Start at 75 mg twice daily, increase to 150 mg twice daily within 1 week based on tolerance 6. Do not exceed 450 mg daily—doses above this provide no additional benefit but significantly increase adverse events 1, 6.
Choose amitriptyline (25-50 mg nightly) when:
- Sleep disturbance is prominent 1
- Cost is a major concern (generic tricyclic) 4
- Patient is under 65 years old 1
Start at 10 mg at bedtime, increase by 10 mg weekly to target 25-50 mg nightly 4. Avoid in patients ≥65 years due to anticholinergic burden 1. The number needed to treat for 50% pain relief is 4.1, meaning only 1 in 4 patients achieves substantial benefit 4.
Important Medication Caveats
- All three medications show only small to moderate benefits with effect sizes that are often not clinically relevant 3
- Approximately 50% of patients achieve at least 30% pain reduction with duloxetine or pregabalin 1
- Therapeutic effects typically emerge over 3-7 weeks 4
- Regular reassessment every 4-8 weeks is essential to evaluate efficacy and adjust treatment 1
Third-Line: Consider Tramadol
If first-line medications are ineffective, tramadol can be considered (Level Ib, Grade A evidence), but use with caution given opioid-related risks. 1
Medications to Absolutely Avoid
Never prescribe corticosteroids or strong opioids for fibromyalgia—they lack efficacy and cause significant harm. 1, 4, 7
- NSAIDs as monotherapy show no benefit over placebo 1, 7
- Strong opioids have not demonstrated benefits and carry substantial risk 1, 7
Treatment Monitoring
Reassess every 4-8 weeks using:
- Pain intensity (0-10 numeric rating scale) 4
- Fibromyalgia Impact Questionnaire (FIQ) 2
- Functional status and quality of life measures 4
If no improvement after an adequate trial (6-8 weeks at target dose), switch to an alternative first-line medication from a different class rather than combining medications 1.