Fibromyalgia Management
Start with Exercise—Not Medication
Begin immediately with a graduated aerobic exercise program as your primary intervention; this is the only "strong-for" therapy with Level Ia, Grade A evidence and should be established before considering any pharmacologic treatment. 1, 2
Exercise Protocol (First-Line, Mandatory)
- Week 0-2: Start with 10-15 minutes of low-impact aerobic activity (walking, swimming, or cycling) 2-3 times weekly at an intensity the patient can tolerate without symptom flare 1, 2
- Week 3-6: Gradually increase duration to 20-30 minutes per session, maintaining 2-3 sessions weekly 1, 2
- Week 7-12: Progress to 30-60 minutes, 5 days weekly as tolerated 2
- After Week 8: Add progressive resistance training 2-3 times weekly targeting major muscle groups once aerobic tolerance is established 1, 2
Heated pool therapy with or without exercise provides additional benefit (Level IIa, Grade B) and may improve exercise tolerance, particularly for patients with mobility limitations. 1, 3
Additional Non-Pharmacologic Therapies (Add at 4-6 Weeks if <30% Improvement)
- Cognitive behavioral therapy (CBT) is recommended for patients with comorbid depression, anxiety, or maladaptive coping strategies (Level Ia, Grade A) 1, 2
- Manual acupuncture (not electro-acupuncture) improves quality of life with Level Ia, Grade A evidence; requires twice-weekly sessions for minimum 8 weeks with 20-30 minute needle retention and manual stimulation 1
- Meditative movement therapies (tai chi, yoga, qigong) significantly improve sleep (effect size -0.61) and fatigue (effect size -0.66) with Level Ia, Grade A evidence 1, 2
- Mindfulness-based stress reduction can help manage symptoms (Level Ia, Grade A) 2
Pharmacologic Management (Second-Line Only)
Reserve medications for patients with severe pain or sleep disturbance that persists after 4-6 weeks of optimized exercise, sleep hygiene, and CBT. 1
First-Line Medication Options (Choose ONE Based on Symptom Profile)
Duloxetine 60 mg once daily is the preferred first choice for patients with comorbid depression or anxiety; start at 30 mg daily for 1 week, then increase to 60 mg daily (Level Ia, Grade A). 1, 2, 3 Never exceed 60 mg/day—higher doses provide no additional benefit and only increase adverse events. 1
Pregabalin 300-450 mg/day in divided doses is preferred for patients with predominant pain without mood symptoms; start at 75 mg twice daily, titrate to 150 mg twice daily over 1 week (Level Ia, Grade A). 1, 2, 3 Never exceed 450 mg/day—higher doses do not improve efficacy and increase dose-dependent adverse reactions. 1 Adjust dose for creatinine clearance <60 mL/min. 1
Amitriptyline 25-50 mg at bedtime is recommended for patients with prominent sleep disturbance; start at 10 mg nightly, increase by 10 mg weekly to target 25-50 mg (Level Ia, Grade A). 1, 2, 3 In elderly patients ≥65 years, use extreme caution due to anticholinergic burden causing falls, confusion, constipation, and urinary retention—start at 10 mg and titrate slowly. 3
Treatment Algorithm After Starting First-Line Medication
- Week 4-6: If pain reduction is <30%, switch to an alternative first-line agent from a different drug class 1
- Week 4-6: If partial response (30-50% pain reduction), consider adding a second agent from a different class 1
- After two failed first-line agents: Add tramadol (the only opioid with evidence; moderate effect size 0.657) with careful monitoring for opioid-related risks (Level Ib, Grade A) 1, 4
Critical Medications to AVOID (Strong Consensus Against)
Never prescribe strong opioids (morphine, oxycodone, hydrocodone, fentanyl)—they lack demonstrated efficacy for fibromyalgia and cause significant harm including dependence. 1, 2, 3
Never prescribe systemic corticosteroids—they have no role in fibromyalgia treatment and lack efficacy. 1, 2, 3
Do not use NSAIDs as monotherapy—they provide no benefit over placebo because fibromyalgia is not an inflammatory condition. 1, 5
Monitoring and Reassessment
- Evaluate treatment response every 4-8 weeks using pain scores (0-10 scale), functional status, and patient global impression of change 2, 3
- Set realistic expectations: Most treatments show modest effect sizes (standardized mean differences 0.3-0.8); expect 30-50% pain reduction rather than complete resolution 1, 2
- Multicomponent therapy combining exercise, CBT, and medication may provide greater benefit than any single intervention 1, 2, 3
Common Pitfalls to Avoid
Do not initiate pharmacotherapy before establishing an aerobic exercise program—exercise is the foundation of care and the only intervention with "strong-for" recommendation. 1, 2
Do not exceed duloxetine 60 mg/day or pregabalin 450 mg/day—higher doses only increase adverse events without added benefit. 1
Do not rely solely on medication without implementing exercise and behavioral approaches—this leads to suboptimal outcomes. 1
Do not discontinue medications abruptly—taper gradually over 2-4 weeks to minimize withdrawal symptoms. 4