11-27-2023 Healthcare

What You Need to Know About Fibromyalgia Treatment

By Jillian Foglesong Stabile, MD

If you’ve been diagnosed with fibromyalgia, you may be wondering what to do next. Fibromyalgia is a very common condition that is difficult to diagnose and the cause is unclear. Fibromyalgia causes widespread pain and frequently is associated with chronic fatigue, insomnia, and depression.

Who gets fibromyalgia?

Fibromyalgia is one of the more common chronic pain conditions. It is estimated to affect about 2% of people in the United States. Fibromyalgia is significantly more common in women than in men, anywhere from two to 14 times more common. Other factors that make you more likely to develop fibromyalgia include:

Middle age (most commonly age 20-50)
Autoimmune diseases such as lupus or rheumatoid arthritis
Post-traumatic stress disorder (PTSD)
Family history of fibromyalgia
Viral infection or other illness
Obesity

What are the symptoms of fibromyalgia?

Fibromyalgia presents with widespread musculoskeletal pain and multiple tender points in the muscles. It can cause chronic pain, poor sleep, fatigue, mood problems, stiffness all over the body, migraines, numbness/tingling in hands and feet, pain in jaw or temporomandibular joint syndrome (TMJ), abdominal pain, bloating, constipation, irritable bowel syndrome, and problems with thinking, memory, and concentration. The symptoms of fibromyalgia are very similar to other conditions, which makes it harder to diagnose.

How is fibromyalgia diagnosed?

Fibromyalgia is diagnosed clinically, which means that no lab or imaging test confirms the diagnosis. Lab testing is sometimes necessary to rule out other conditions that can have similar symptoms. Some of these other conditions your provider may want to rule out before diagnosing you with fibromyalgia include:

Polymyalgia rheumatica
Spondylarthritis
Inflammatory myopathy
Systemic inflammatory arthropathies
Hypothyroidism
Hyperthyroidism
Myofascial pain syndrome
Chronic fatigue syndrome
Systemic sclerosis

Testing for fibromyalgia is generally to rule out other conditions. Your healthcare provider may recommend a complete blood count to rule out anemia, inflammatory labs to rule out other rheumatologic conditions, a comprehensive metabolic panel, or thyroid function testing. There is a newer blood test called the FM/a test, which may show some promise as a diagnostic test for fibromyalgia when used in combination with other diagnostic criteria. This test is not commonly used and is very expensive, so the diagnosis of fibromyalgia is not dependent on doing this test.

Several criteria have been developed to try to help with the diagnosis of fibromyalgia.

Fibromyalgia rapid screening tool (FiRST)

The FiRST tool is one of the initial screening tools that may be used to determine if fibromyalgia may be present. You can use this tool yourself at home to help decide if you need to see a healthcare provider. The FiRST tool is a series of 6 questions. Having five or more positive answers is suggestive of fibromyalgia:

Do you have pain all over your body?
Is your pain accompanied by a continuous and very unpleasant general fatigue?
Does your pain feel like burns, electric shocks, or cramps?
Is your pain associated with other health problems such as digestive problems, urinary problems, headaches, or restless legs?
Is your pain accompanied by other unusual sensations throughout your body, such as pins and needles, tingling, or numbness?
Does your pain significantly impact your life, sleep, and ability to concentrate or make you feel slower in general?

Analgesic, Anesthetic, and Addiction (AAPT) 2019 Diagnostic Criteria for Fibromyalgia

The AAPT also developed a set of diagnostic criteria to try to standardize the diagnosis of fibromyalgia. The AAPT has 3 primary criteria:

Multisite pain, defined as six or more pain from nine possible sites: head, arm (right or left), chest, abdomen, back or spine (upper or lower), leg (right or left)
Moderate to severe sleep problems or fatigue
Symptoms for at least 3 months

American College of Rheumatology fibromyalgia diagnostic criteria

The American College of Rheumatology also has a set of diagnostic criteria that was initially developed in 2010 and revised in 2016. Your healthcare provider will consider criteria like where you are having pain, a widespread pain index, and how long your symptoms have been going on as well as a symptom severity score for related symptoms to make the diagnosis of fibromyalgia.

Is fibromyalgia curable?

The short answer is no; there is no cure for fibromyalgia. Several treatment options include lifestyle modification, behavioral interventions, and medications that may help you manage the symptoms associated with fibromyalgia and improve your quality of life.

What are non-pharmacologic options for treating fibromyalgia?

The most important thing that you can do to manage your fibromyalgia symptoms is to educate yourself on the condition and what to expect. There is evidence that patient education actually improves outcomes. Many websites may help you learn more about your condition. The University of Michigan has a pain guide, and the National Fibromyalgia Association has reliable information regarding the condition as well.

Exercise

Exercise is the next non-pharmacologic treatment for fibromyalgia that has been shown to improve quality of life. If you already exercise regularly, then moderate-intensity exercise is fine. If you don’t have a regular exercise program, then talk to your healthcare provider about a low-intensity, low-frequency exercise program that can gradually build to a moderate exercise program. A low-intensity exercise program may include aerobic, resistance, stretching, or some combination of these.

Mental and behavioral health

Mental health and behavioral modification can help you with your symptoms as well. Cognitive behavioral therapy is a type of therapy that teaches you how to work on your thoughts and behaviors. It can help you modulate your responses and improve your chronic pain, fatigue, and sleeping problems. Moderate evidence suggests that this is helpful with chronic pain associated with fibromyalgia.

Complementary and alternative medicine

There is less evidence to support the use of other complementary and alternative medication options for the management of fibromyalgia symptoms. Fewer studies evaluate the potential benefits of these therapies. Alternative options include acupuncture, massage, meditation, or herbs and supplements. Yoga, Pilates, and tai chi have shown some improvement in function and pain, but these fall into the exercise category. Acupuncture may have some benefits, but studies are mixed. Manual therapies such as myofascial release have also shown some benefit for pain improvement by acting on the nociceptive pathways involved in the process of central sensation. Other possible therapies have less evidence supporting their use and are outside the scope of our discussion.

Pharmacologic therapies for the management of fibromyalgia

Several classes of medications are used to treat fibromyalgia. While none of these medications will cure the condition, they may improve your pain and quality of life. A general approach to medication for fibromyalgia is to start one medication and gradually increase the medication over 3 months to give it a fair trial unless the side effects are intolerable. If you don’t respond to a medication, your healthcare provider will review whether you have been on the maximum tolerated dose, are taking your medication regularly, or if other conditions may be contributing to the symptoms.

Tricyclic antidepressants

The first class of medications used to treat fibromyalgia symptoms is tricyclic antidepressants. Amitriptyline is the most recommended and researched medication for fibromyalgia in this category. It is primarily used for pain reduction. Common side effects include dry mouth, constipation, dizziness, urinary retention, and sedation. It is usually dosed at night.

Cyclobenzaprine is a muscle relaxer that is commonly used for fibromyalgia pain. It is derived from the tricyclic antidepressants. It is also used primarily for pain reduction and can cause sedation, seizures, arrhythmias, and confusion.

Serotonin-norepinephrine reuptake inhibitor (SNRI)

Several medications in the SNRI class are used for treating fibromyalgia pain. These medications may improve pain and mood symptoms. They include duloxetine and milnacipran. These medications can cause nausea, dry mouth, fatigue, constipation, decreased appetite, increased heart rate, and high blood pressure. They do contain an FDA black box warning for increased suicide risk in children, adolescents, and young adults with major depression or other psychiatric problems.

Anticonvulsants

Anti-seizure medications are the final class of medications approved for use in fibromyalgia. While the more commonly used medication is gabapentin, this medication is technically off-label for use in fibromyalgia. This means that fibromyalgia is not officially listed as an approved diagnosis for the medication. That said, it is commonly prescribed by healthcare providers for this condition. Pregabalin is the other medication in this class that is used to treat fibromyalgia. This medication may help with pain, fatigue, sleep, and quality of life. Pregabalin is associated with dizziness, sleepiness, dry mouth, and blurred vision.

Pain medications

Generally speaking, pain medication is not recommended for fibromyalgia. Tramadol is sometimes used to treat pain. It’s mostly used for severe symptoms in the short term. Naltrexone is an opioid receptor antagonist that can treat pain and depression associated with fibromyalgia as well.

Other treatments

Other medications are being investigated as potential treatments for fibromyalgia pain and some of the other symptoms associated with fibromyalgia. These are not currently recommended regularly for the treatment of fibromyalgia.

Fibromyalgia is an extremely common condition, and it can significantly impact your quality of life. It is important to be open with your healthcare provider about any symptoms you may be experiencing and any potential side effects of your medication.

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Dr. Foglesong Stabile is a board-certified Family Physician who enjoys full scope Family Medicine, including obstetrics, women’s health, and endoscopy, as well as caring for children and adults of all ages. She also teaches the family medicine clerkship for Pacific Northwest University of Health Sciences.

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