What are the diagnostic criteria and recommended management for fibromyalgia?

Fibromyalgia: Diagnosis and Management

Diagnostic Criteria

Diagnose fibromyalgia when a patient has chronic widespread pain affecting all four body quadrants for at least 3 months, accompanied by fatigue, sleep disturbances, and cognitive dysfunction, with pain disproportionate to any identifiable tissue damage. 1

The diagnosis is entirely clinical and does not require tender point examination (the older 1990 criteria requiring 11 of 18 tender points has been superseded). 1, 2

Key Clinical Features to Document:

• Pain distribution: Must involve all four body quadrants (upper/lower, left/right) for minimum 3 months 1, 2
• Associated symptoms: Fatigue disproportionate to activity, non-restorative sleep, cognitive dysfunction ("fibro fog"), and mood disturbances (anxiety/depression) 2
• Pain characteristics: Hyperalgesia (increased pain response) and allodynia (pain from normally non-painful stimuli) 2
• Demographics: Most common in women aged 30-60 years, affects approximately 2-5% of the population 2, 3

Essential Laboratory Testing

Order only these specific tests to exclude mimicking conditions, not to confirm fibromyalgia: 1

• Complete blood count (CBC) 1
• Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) 1, 2
• Thyroid-stimulating hormone (TSH) 1, 2
• Creatine kinase (CK) 1, 2
• Rheumatoid factor and anti-CCP antibodies (only if inflammatory arthritis suspected) 1

Common pitfall: Avoid extensive imaging or additional laboratory testing—fibromyalgia diagnosis is clinical, and over-testing delays diagnosis (average 2+ years with 3.7 physician consultations) and increases healthcare costs. 2

Treatment Algorithm

Step 1: Immediate Interventions (Start Day 1)

Begin with patient education explaining fibromyalgia as a central nervous system pain processing disorder, not tissue damage, combined with aerobic and strengthening exercise as the primary intervention. 1

• Patient education: Explain the condition as disordered central pain processing, not progressive tissue damage, to reduce anxiety and establish realistic expectations 1, 4
• Exercise prescription: Initiate graded aerobic exercise (walking, swimming, cycling) plus resistance training, gradually increasing intensity over 8-12 weeks 1, 5
  • This has Level Ia, Grade A evidence as the single strongest intervention for pain, sleep, fatigue, and function 1, 5
  • Start low-intensity to avoid symptom flare, increase gradually 5

Step 2: Add Complementary Non-Pharmacological Therapies

Consider adding one or more of these evidence-based therapies based on patient preference and access: 1

• Cognitive behavioral therapy (CBT) for chronic pain management and mood disorders 1, 5, 4
• Heated pool therapy/hydrotherapy 1
• Yoga (particularly effective for neck/back pain and headaches) 1, 5
• Tai chi or mindfulness-based stress reduction 1, 5
• Manual acupuncture 1

All have Level Ia, Grade A evidence. 1

Step 3: Pharmacological Management (Symptom-Targeted)

Select ONE first-line medication based on the patient's predominant symptom profile: 1

• Amitriptyline 10-25 mg at bedtime: For pain with sleep disturbance 1, 5

  • Start low-dose, titrate slowly
  • Also addresses mood symptoms 5

• Duloxetine 30-60 mg daily: For pain with comorbid depression/anxiety 1, 5

  • Do NOT escalate beyond 60 mg/day (no additional benefit, increased side effects) 1
  • Strong evidence of benefit 3, 4

• Pregabalin 150-450 mg daily in divided doses: For pain as primary symptom 1

  • Adjust dose for creatinine clearance <60 mL/min 1
  • Do NOT exceed 450 mg/day 1
  • Also improves sleep 5

• Alternative: Gabapentin 1800-2400 mg daily in divided doses for neuropathic pain components 5

• Alternative: Milnacipran for severe pain with depression 5, 4

Step 4: Critical Medications to AVOID

Never prescribe strong opioids, corticosteroids, or NSAIDs as monotherapy for fibromyalgia—they have no demonstrated benefit with significant harm (Level Ia, Grade A evidence). 1

• Opioids: No proven benefit, high addiction potential, worsens central sensitization 1, 3, 4
• NSAIDs: Ineffective for centralized pain, no benefit demonstrated 1, 3, 4
• Corticosteroids: No role in fibromyalgia management 1

Exception: Tramadol may be used cautiously for breakthrough pain only, given addiction potential 5

Monitoring and Follow-Up

Reassess every 4-8 weeks initially using standardized measures (Fibromyalgia Impact Questionnaire) to evaluate treatment efficacy, adjusting the plan based on response, tolerability, and patient goals. 1, 2

• Measure functional impact on daily activities, pain intensity, fatigue, sleep quality, and functioning 2
• Adjust or switch medications if inadequate response after 8 weeks at therapeutic dose 1
• Reinforce exercise and non-pharmacological therapies at each visit 1

Additional Considerations

Sleep Optimization

• Address through sleep hygiene education 5
• Low-dose amitriptyline or pregabalin specifically target sleep disturbance 5

Comorbidity Management

• Screen for and treat coexisting conditions: irritable bowel syndrome, migraine, chronic fatigue syndrome, mood disorders 2, 6
• Consider multidisciplinary team (pain specialist, physical therapist, psychologist) for complex cases 5

The key to successful fibromyalgia management is establishing the diagnosis early, providing reassurance through education, and implementing a combined non-pharmacological and targeted pharmacological approach—not chasing a cure, but optimizing function and quality of life. 1, 4