Concise review
Recognizing for clinicians
Improving the Recognition and Diagnosis of Fibromyalgia
Lesley M. Arnold, MD; Daniel J. Clauw, MD; and Bill H. McCarberg, MD;
for the FibroCollaborative
Fibromyalgia (FM) is a chronic widespread pain disorder often
seen in primary care practices. Advances in the understanding of
FM pathophysiology and clinical presentation have improved the
recognition and diagnosis of FM in clinical practice. Fibromyalgia
is a clinical diagnosis based on signs and symptoms and is appro-
priate for primary care practitioners to make. The hallmark symp-
toms used to identify FM are chronic widespread pain, fatigue,
and sleep disturbances. Awareness of common mimics of FM
and comorbid disorders will increase confidence in establishing
a diagnosis of FM.
Mayo Clin Proc. 2011;86(5):457-464
ACR = American College of Rheumatology; CRP = C-reactive protein;
ESR = erythrocyte sedimentation rate; FM = fibromyalgia; RA = rheu-
matoid arthritis.
F ibromyalgia (FM), a chronic widespread pain disorder,
is estimated to affect more than 5 million Americans
(2%-5% of the adult population).1-3 It is second only to
osteoarthritis as the most common disorder seen in rheu-
matology practices.4 In recent years, increasingly more pa-
tients with FM are presenting to primary care clinicians for
initial diagnosis and ongoing care.
Fibromyalgia is a persistent and potentially debilitating
disorder that can have a devastating effect on quality of
life, impairing the patient’s ability to work and participate
in everyday activities, as well as affecting relationships
with family, friends, and employers.5 It imposes heavy eco-
nomic burdens on society as well as on the patient.6,7
Recent research suggests that the chronic widespread
pain that is the hallmark symptom of FM is neurogenic in
origin.8 Fibromyalgia is associated with a central amplifi-
cation of pain perception characterized by allodynia (ie, a
heightened sensitivity to stimuli that are not normally pain-
ful) and hyperalgesia (ie, an increased response to painful
stimuli). Neuroimaging studies have also shown that FM
is associated with aberrant processing of painful stimuli in
the central nervous system.9,10
Accurate diagnosis is the critical first step to more ef-
fective care and better outcomes for patients with FM. De-
veloped by the FibroCollaborative, a diverse group of lead-
ing experts on FM, this review aims to discuss the current
understanding of FM symptomatology and diagnostic ap-
proaches. Methods for recognizing patients who may have
FM on the basis of presentation of symptoms and associ-
ated disorders are described, as well as important steps in
Mayo Clin Proc. • May 2011;86(5):457-464 • doi:10.4065/mcp.2010.0738
For personal use. Mass reproduce only with permission from Mayo
a Clinic Proceedings.
and diagnosing fibromyalgia
the differential diagnosis, including the role of the physical
examination, laboratory testing, and referrals to specialists
to identify both disorders that can mimic FM and those that
frequently coexist with FM.
UNDERDIAGNOSIS
Despite improved understanding of its pathologic pro-
cesses, FM remains undiagnosed in as many as 3 out of
4 people with the condition (Data on file. Decision Re-
sources report 2009. Pfizer, New York, NY). Diagnosis
time averages 5 years,11 resulting in delayed treatment and
potentially suboptimal medical care. Women currently ac-
count for 80% to 90% of cases diagnosed using the Ameri-
can College of Rheumatology (ACR) 1990 criteria for FM
(prevalence, 3.4% in women vs 0.5% in men).1 Women are
more sensitive to painful stimuli than men and therefore
have a greater response than men to the diagnostic tender
point examination that is included in the ACR criteria (ten-
derness on digital palpation at predesignated sites). As a
result, men with chronic widespread pain rarely meet ACR
criteria for FM, despite having a similar underlying patho-
logic process.12
From the Department of Psychiatry and Behavioral Neuroscience and the
Women’s Health Research Program, University of Cincinnati College of Medi-
cine, Cincinnati, OH (L.M.A.); Department of Anesthesiology, Medicine, and
Psychiatry, University of Michigan, Ann Arbor (D.J.C.); and Chronic Pain Man-
agement Program, Kaiser Permanente, Escondido, CA (B.H.M.). A list of the
additional members of the FibroCollaborative appears on page 464.
Dr Arnold has received grants/research support from Eli Lilly and Company,
Pfizer, Cypress Biosciences, Wyeth Pharmaceuticals, Boehringer Ingelheim, Al-
lergan, and Forest Laboratories. She is a consultant for Eli Lilly and Company,
Pfizer, Cypress Biosciences, Wyeth Pharmaceuticals, Boehringer Ingelheim,
Forest Laboratories, Allergan, Takeda, UCB, Theravance, AstraZeneca, and
sanofi-aventis. Dr Clauw has received grants/research support from Pfizer
and Forest Laboratories. He is a consultant for Pfizer, Eli Lilly and Company,
Forest Laboratories, Cypress Biosciences, Pierre Fabre Pharmaceuticals,
UCB, and AstraZeneca. Dr Clauw is a member of the advisory boards for
Pfizer, Eli Lilly and Company, Forest Laboratories, Cypress Biosciences, Pierre
Fabre Pharmaceuticals, UCB, and AstraZeneca. Dr McCarberg has received
honoraria from Cephalon, Eli Lilly and Company, Endo Pharmaceuticals, Forest
Laboratories, Merck & Co., Pfizer, and Purdue Pharma. The FibroCollaborative
group was sponsored by Pfizer.
This article is freely available on publication, because the authors have cho-
sen the immediate access option.
A question-and-answer section appears at the end of this article.
Individual reprints of this article are not available. Address correspondence to
Lesley M. Arnold, MD, 222 Piedmont Ave, Suite 8200, Cincinnati, OH 45219
(lesley.arnold@uc.edu).
© 2011 Mayo Foundation for Medical Education and Research
• www.mayoclinicproceedings.com 457
Recognizing and diagnosing fibromyalgia
IMPORTANCE OF IMPROVED
RECOGNITION AND DIAGNOSIS
Establishing the diagnosis of FM is an essential component
of successful management.4 Many patients with FM have
been living with chronic pain and other troubling and dis-
abling symptoms for extended periods. Primary care practic-
es undoubtedly see more patients with FM than is currently
appreciated. When such patients are finally recognized and
a diagnosis is confirmed, both clinician and patient clear a
major hurdle to more effective management of the disorder.
Research shows that the diagnosis of FM has no nega-
tive effect on clinical outcomes. Indeed, patients newly di-
agnosed as having FM report improved satisfaction with
health and fewer long-term symptoms.13 In addition, sev-
eral studies have indicated that the utilization of medical
resources and the associated costs decline after a diagnosis
of FM.14,15 Patients with FM appreciate sincere efforts to
help them and can be gratifying to treat.
The diagnostic evaluation of FM can take time, but this
should not be a barrier in primary care practices. If a di-
agnosis of FM is suspected, a trial of treatment can begin
while the evaluation for possible other coexisting disor-
ders continues. Subsequent visits during initial diagnosis
and management actually reassure the patient with FM
that they are receiving appropriate care and validation,
which can be very therapeutic.
A PRACTICAL APPROACH TO
RECOGNITION AND DIAGNOSIS
Fibromyalgia is a clinical diagnosis based on the disorder’s
unique clinical characteristics and not solely a diagnosis
of exclusion. Like other pain states (eg, migraine), FM is
commonly diagnosed in the primary care setting on the ba-
sis of characteristic symptoms.
A focused history and physical examination are the cor-
nerstones of FM recognition. No laboratory or radiologic
testing is required to diagnose FM. Such tests are necessary
only if clinically indicated to evaluate other potential diag-
noses, including conditions that may be comorbid with FM.
Routine laboratory tests may help guide the assessment,
especially if they have not been performed at some point
in the patient’s work-up. Specialist referral is usually not
necessary to confirm the diagnosis. The goal is to identify
FM and initiate treatment as early as possible, even if fur-
ther evaluation is needed to identify and confirm possible
comorbid conditions that may also require management.
Patient History
Core Symptoms of FM. The core symptoms of FM can
be visualized as a triad that includes chronic widespread
458 Mayo Clin Proc. • May 2011;86(5):457-464 • doi:10.4065/mcp.2010.0738
For personal use. Mass reproduce only with permission from Mayo
a Clinic Proceedings.
pain (in the right and left side of the body, above and below
the waist, and in the axial skeleton) of long duration (≥3
months) as the primary, hallmark symptom, with fatigue16
and sleep disturbance (including nonrestorative sleep [ie,
feeling unrefreshed after a night’s sleep])5,16 as 2 other
commonly associated symptoms. These 3 symptoms occur
in most patients with FM. Presentation of chronic wide-
spread pain for years, especially in the presence of fatigue
and sleep disturbance, should raise suspicion for FM. For
many patients, the fatigue commonly associated with FM
is the most troublesome symptom and the one that leads
them to seek medical attention.
Other key associated symptoms include tenderness,
stiffness, mood disturbances (eg, depression and/or anxi-
ety), and cognitive difficulties (eg, trouble concentrating,
forgetfulness, and disorganized thinking).17-20 Fibromyalgia
symptoms can wax and wane, varying in intensity from day
to day and by physical location. Patients with FM frequently
report impairment in multiple areas of function, especially
physical function.5 Overall, patients with FM are a hetero-
geneous population. The impact of FM spans the continuum
from patients who are mildly to moderately affected by FM
symptoms to those who are more severely affected and have
markedly impaired function and quality of life.
Fibromyalgia should be considered in all patients with
multiple regions of chronic pain (at a single point in time
or during the course of their lifetime), especially if they
report multiple somatic symptoms. Generally, the index of
suspicion for FM should increase the longer the chronic
widespread pain and other symptoms have been present,
the more variable the symptoms seem, and the more body
systems that are involved.
Comorbid Disorders. The presence of common co-
morbid disorders can also raise suspicion for FM, and it
is important for the clinician to ask about chronic wide-
spread pain when presented with these associated condi-
tions. Examples of common comorbid disorders include
mood or anxiety disorders, which can precede the de-
velopment of FM. The lifetime (both current and past)
prevalence of these disorders with FM is high, with any
lifetime anxiety disorder reported in 35% to 62% of pa-
tients, lifetime major depressive disorder in 58% to 86%
of patients, and lifetime bipolar disorder in up to 11%
of patients.21,22 The high frequency with which FM and
mood and anxiety disorders occur together is most likely
explained by pathophysiologic abnormalities common to
both mood and anxiety disorders and FM, rather than by
FM causing the mood and anxiety disorders or the mood
and anxiety disorders causing FM.23 Although psychiatric
disorders often occur together with FM, they should not
be confused with FM or viewed as being the same disor-
der.22 As comorbid conditions, mood and anxiety disor-
• www.mayoclinicproceedings.com

ders need to be treated together with FM, sometimes with
different interventions. Treatment aimed at mood alone
may result in suboptimal outcomes for the management
of all of the symptoms of FM.24
Other common comorbid disorders in patients with FM
include the following regional pain syndromes that may
share certain pathophysiologic features with FM: irritable
bowel syndrome, tension-type headache/migraine, inter-
stitial cystitis or painful bladder syndrome, chronic prosta-
titis or prostadynia, temporomandibular disorder, chronic
pelvic pain, and vulvodynia.24,25 Patients may focus on
local areas of pain and describe one particularly bother-
some area; others may hesitate to mention all of their pain
symptoms, especially if some of their pain has been dis-
missed or discounted previously. Therefore, it is impor-
tant for clinicians to determine whether pain is limited to
1 or more regions of the body or whether the pain is more
widespread.
Fibromyalgia Risk Factors. The patient’s history may
reveal risk factors for FM, such as familial predisposition.
Relatives of people with FM are at a higher risk. In a recent
family study, first-degree relatives of patients with FM were
8 times more likely to have FM than relatives of the control
group of patients with rheumatoid arthritis (RA).26 Environ-
mental factors, including physical trauma or injury, infec-
tions (eg, Lyme disease and hepatitis C), and other stressors
(eg, work, family, life-changing events, and abuse history),
pose additional risk.27 Finally, sex is a risk factor. Women are
diagnosed as having FM approximately 7 times more often
than men; however, the source of at least some of this dispar-
ity appears to be an artifact of requiring a certain degree of
tenderness to diagnose FM using ACR criteria.28
Medical History Tools. Tools are available to facilitate
a focused medical history in the time-constrained primary
care setting. The use of a body pain diagram during the ini-
tial examination can assist patients in documenting the pres-
ence of widespread pain and establish a baseline for moni-
toring treatment response. Patient screening can begin in the
office waiting area using brochures that include a body pain
diagram and a simple questionnaire, with questions such as
the following: Have you had pain in your muscles or joints
that has lasted 3 months or more? Do you have pain all over?
Do you become fatigued during the day so that you have to
stop normal activities? Do you wake up in the morning and
feel more tired than when you went to bed?
Physical Examination
The physical examination of a patient with suspected FM
should focus on identifying associated or comorbid dis-
orders as warranted by symptoms, signs, and the medical
history because these may require separate management.
Joints should be examined for swelling, tenderness, range
Mayo Clin Proc. • May 2011;86(5):457-464 • doi:10.4065/mcp.2010.0738
For personal use. Mass reproduce only with permission from Mayo
a Clinic Proceedings.
Recognizing and diagnosing fibromyalgia
of motion, and crepitus, and patients should be evaluated
for peripheral pain generators (eg, RA, osteoarthritis, ten-
donitis, adhesive capsulitis) as well as focal and/or objec-
tive weakness. If the history is suggestive, signs of con-
nective tissue disease should be assessed and a neurologic
examination conducted. It is important to note that the
presence of a second disorder (even a painful one) does
not necessarily exclude a diagnosis of FM, which can oc-
cur together with other painful conditions.29 In general,
the physical examination findings are normal in FM ex-
cept for diffuse tenderness,30 evaluated by counting ten-
der points or by digital palpation of several regions of the
body. The physical examination (regardless of whether
tender points are counted) remains key in the evaluation
of patients to assess the tenderness (allodynia and hype-
ralgesia) associated with FM as well as to aid in the dif-
ferential diagnosis.
FORMAL CLASSIFICATION CRITERIA
The ACR criteria for FM (Figure 1) include a history
of widespread pain lasting 3 months or longer.31 Wide-
spread pain is defined as pain above and below the waist
and on both sides of the body. In addition, axial skeletal
pain (in the cervical spine, anterior chest, thoracic spine,
or lower back) must be present. According to the ACR,
a patient must have pain on digital palpation at 11 of
18 predesignated sites, commonly referred to as tender
points, to be diagnosed as having FM. Approximately
4 kg of pressure must be applied to a site, and the pa-
tient must indicate that the site is painful.32 In practi-
cal terms, the pressure to assess tenderness with digital
examination is the pressure needed to see your own nail
bed blanch.
The ACR criteria have a sensitivity of 88.4% and a
specificity of 81.1%.31 Many health care professionals find
the manual tender point examination useful for confirm-
ing the presence of widespread tenderness and increasing
confidence in the diagnosis.33 These criteria were originally
designed to standardize patient classification in clinical tri-
als rather than to diagnose FM in routine clinical practice.12
Nevertheless, the tender point examination has been used
in hundreds of studies and is recognized by the ACR for the
diagnosis of FM.
As a possible alternative to the ACR criteria for use in
clinical settings, Wolfe et al34 recently proposed clinical
diagnostic criteria for FM that do not rely on counting ten-
der points. The proposed criteria take into account not only
pain but also other FM-related symptoms and are intended
to assess the severity of those symptoms (Table 1).34 To ad-
minister the Widespread Pain Index and Symptom Severity
scale, the physician asks the patient to report the location
• www.mayoclinicproceedings.com 459
Recognizing and diagnosing fibromyalgia

History of widespread pain (present for ≥3 mo)

Definition: Pain is considered widespread when all of the follow-
ing are present: pain on both sides of the body, pain above and
below the waist. In addition, axial skeletal pain (cervical spine,
anterior chest, thoracic spine, or low back pain) must be present.
“Low back” pain is considered lower segment pain
Pain in 11 of 18 standardized sites, commonly referred to as tender
points, on digital palpation
Occiput (2)—at the suboccipital muscle insertions
Low cervical (2)—at the anterior aspects of the intertransverse
spaces at C5 to C7
Trapezius (2)—at the midpoint of the upper border
Supraspinatus (2)—at origins, above the scapula spine near the
medial border
Second rib (2)—upper lateral to the second costochondral junction
Lateral epicondyle (2)—2 cm distal to the epicondyles
Gluteal (2)—in upper outer quadrants of buttocks in anterior fold
of muscle
Greater trochanter (2)—posterior to the trochanteric prominence
Knee (2)—at the medial fat pad proximal to the joint line
Digital palpation should be performed with an approximate force of 4
kg. A tender point has to be painful at palpation, not just tender

FIGURE 1. American College of Rheumatology 1990 criteria for the classification of fibromyalgia.
Adapted from Arthritis Rheum,31 with permission.

of any pain during the past week at 19 sites, including areas
of the shoulders, arms, hips, legs, jaws, chest, abdomen,
back, and neck. The Symptom Severity scale focuses on 3
physical symptoms, as well as somatic symptoms in gen-
eral. Fatigue, waking unrefreshed, and cognitive symptoms
are rated on the basis of the level of severity during the
previous week. Table 1 summarizes typical somatic symp-
toms that might be considered.34 Research to determine the
clinical usefulness of these proposed criteria is ongoing.
Studies of other approaches to the identification of patients
with FM in primary care settings are also under way. Many
clinicians also use the previously described core symptoms
to identify patients with FM.
Once FM is diagnosed, treatment should begin even
if further evaluation for comorbid conditions is ongoing.
Identification of disorders that coexist with FM may help
to reveal contributing factors that may need to be addressed
in the comprehensive management plan.
DIFFERENTIAL DIAGNOSIS
Current medications should be identified and medication-
related pain such as statin-induced muscle pain or opioid-
induced hyperalgesia ruled out. Identification of disorders
that can mimic FM (eg, hypothyroidism and inflammatory
rheumatic diseases) or that are frequent comorbid condi-
tions in patients with FM (eg, RA, osteoarthritis, systemic
lupus erythematosus, spinal stenosis, neuropathies, sleep
disorders such as sleep apnea, and mood and anxiety disor-
ders) is essential so that appropriate treatments can be initi-
ated.35 The presence of a second disorder does not exclude
a diagnosis of FM; both disorders will need management.
Laboratory Testing
Extensive laboratory testing is not generally necessary to
diagnose FM.35 A diagnosis of FM can be established on
the basis of the history and physical examination findings
with selective use of laboratory testing.
Although not required to establish the diagnosis of FM,
routine laboratory testing (if not already performed within
the past 6-12 months) is frequently obtained to evaluate other
possible causes of symptoms or signs. These tests include
measurement of erythrocyte sedimentation rate (ESR) and/or
C-reactive protein (CRP) levels, a complete blood cell count,
a comprehensive metabolic panel, and a thyroid function test.
Routine testing for rheumatoid factor or antinuclear antibod-
ies is not recommended to diagnose FM unless the patient has
signs or symptoms suggesting an autoimmune disorder, or if
initial inflammatory indices (ie, ESR and/or CRP level) are
abnormal (recognizing that some patients with RA or system-
ic lupus erythematosus may have normal ESR and/or CRP
values). Depending on symptoms (eg, duration of pain and
acute vs chronic), medical history, and physical examination
findings, other tests, such as measurement of ferritin, vitamin
B12, and vitamin D levels and determination of iron-binding
capacity and percentage of saturation, may be indicated.35
Further Investigation/Specialist Referral
A diagnosis of FM can be established appropriately in the
primary care setting, but specialist referral may be indicat-

460 Mayo Clin Proc. • May 2011;86(5):457-464 • doi:10.4065/mcp.2010.0738 • www.mayoclinicproceedings.com

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 Recognizing and diagnosing fibromyalgia

TABLE 1. Clinical Diagnostic and Severity Criteria for Fibromyalgia: Widespread Pain Index (WPI) and Symptom Severity (SS) Scale
Criteria
A patient satisfies diagnostic criteria for fibromyalgia if the following 3 conditions are met:
WPI ≥7 and SS scale score ≥5 or WPI 3-6 and SS scale score ≥9
Symptoms have been present at a similar level for at least 3 months
The patient does not have a disorder that would otherwise explain the pain
Ascertainment
WPI (0-19)—Directions: Note the number of areas in which the patient has had pain during the past week. In how many areas has the
patient had pain?
Shoulder girdle, left Hip (buttock, trochanter), left Jaw, left Upper back
Shoulder girdle, right Hip (buttock, trochanter), right Jaw, right Lower back
Upper arm, left Upper leg, left Chest Neck
Upper arm, right Upper leg, right Abdomen
Lower arm, left Lower leg, left
Lower arm, right Lower leg, right
SS scale score (0-12) = Symptom Severity + Extent of Somatic Symptoms
Symptom severity—Directions: Using the provided scale, indicate the level of severity experienced for each of the 3 following symptoms:
Fatigue
Waking unrefreshed
Cognitive symptoms
Scale
0 = no problem
1 = mild: slight, mild, or intermittent problems
2 = moderate: considerable problems, often present and/or at a moderate level
3 = severe: pervasive, continuous, life-disturbing problems
Extent of somatic symptoms—Directions: Indicate how many somatic symptomsa the patient has using the following scale
0 = no symptoms
1 = few symptoms
2 = a moderate number of symptoms
3 = a great deal of symptoms
a
Somatic symptoms that might be considered include muscle pain, irritable bowel syndrome, fatigue/tiredness, thinking or remembering prob-
lems, muscle weakness, headache, pain/cramps in abdomen, numbness/tingling, dizziness, insomnia, depression, constipation, pain in upper
abdomen, nausea, nervousness, chest pain, blurred vision, fever, diarrhea, dry mouth, itching, wheezing, Raynaud phenomenon, hives/welts,
ringing in ears, vomiting, heartburn, oral ulcers, loss/change in taste, seizures, dry eyes, shortness of breath, loss of appetite, rash, sun sensitivity,
hearing difficulties, easy bruising, hair loss, frequent urination, painful urination, and bladder spasms.
Adapted from Arthritis Care Res (Hoboken),34 with permission.

ed. The patient should be referred for specialist evaluation
if uncertainty remains about the diagnosis because of un-
usual symptoms or signs, disease course, laboratory find-
ings, or other concerns. Referral should also occur when
the patient has abnormal laboratory results that suggest
another condition requiring specialty care. It may also be
necessary for the treatment of comorbid conditions, includ-
ing mood/anxiety and sleep disorders. Figure 2 and Table 2
summarize the approach to the diagnosis of FM.
CONCLUSION
Fibromyalgia can have a profound effect on a patient’s
quality of life. Despite greater interest in and awareness
of the disorder than ever before, FM remains underdiag-
nosed and undertreated. A greatly improved understanding
of FM and its pathophysiologic underpinnings has helped
explain the varied and often complex constellation of FM
signs and symptoms, resulting in effective new treatment
approaches.
Fibromyalgia is a clinical diagnosis that, similar to other
chronic pain states such as migraine, is appropriate for pri-
mary care practitioners to make. Although routine laboratory
work can help guide the assessment, laboratory or radiologic
testing is required only if clinically indicated for a concomi-
tant disorder. Presentation of some of the hallmark symptoms
(eg, chronic widespread pain, fatigue, and sleep disturbanc-
es) should raise suspicion for FM. A structured and focused
medical history and physical examination can help in the dif-
ferential diagnosis and confirm the diagnosis of FM.
Better health outcomes and quality of life can be achieved
by patients with FM with effective treatments developed
as a result of an enhanced understanding of the disorder.
Clinicians, both individually and in collaboration with other
health care professionals and their patients, can improve
patient care with vigilant recognition and diagnosis of FM.
Editorial support was provided by Dr Gayle Scott, PharmD, of
UBC Scientific Solutions and funded by Pfizer.

Mayo Clin Proc. • May 2011;86(5):457-464 • doi:10.4065/mcp.2010.0738 • www.mayoclinicproceedings.com 461

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a Clinic Proceedings.
Recognizing and diagnosing fibromyalgia

Suspect FM on the basis of presentation of chronic widespread pain ≥3 mo, fatigue, and nonrestorative sleep

Laboratory tests (if not done in past

Patient history Physical examination 6-12 mo) should include:

Assess pain quality, ask about Joint examination: Assess for inflammation Complete blood cell count
hyperalgesia, widespread (synovitis, swelling, and range of motion) Comprehensive metabolic panel
pain ≥3 mo Focused neurologic examination on the Thyroid function test
Concomitant symptoms/history: basis of patient symptoms Erythrocyte sedimentation rate
fatigue, nonrestorative sleep, Tenderness (eg, allodynia), by either ACR and/or C-reactive protein
cognitive impairment, depressive tender point examination or digital
and anxiety symptoms, and palpation in several regions of the body
regional pain disorders
Pain affecting daily activites/quality
of life
Family history of fibromyalgia
Numerical pain scale, patient pain
diagram, or WPI/SS34

FM likelihood high FM likelihood probable FM likelihood low

≥11 of 18 tender points OR WPI/SS ≥11 of 18 tender points OR WPI/SS <11 of 18 tender points identified
criteria met criteria met OR does not meet WPI/SS criteria AND
Physical examination otherwise Abnormal findings on PE and/or Abnormal findings on PE and/or
normal laboratory tests laboratory tests
Laboratory results within normal
limits Red flags to prompt additional differential diagnosis
• Prominent focal abnormalities (eg, numbness, weakness)
• Joint swelling, redness, heat
• Fever
• Rash, skin ulcers, or alopecia
• Abnormal laboratory findings
• Patient taking medications that cause some FM-like symptoms
(eg, muscle soreness due to a statin)

Use clinical judgment as to whether

Initiate FM treatment and continue initiating FM treatment would benefit
work-up on the basis of patient and continue work-up on the
Initiate FM treatment symptoms/comorbid conditions basis of clinical findings

Individualize to patient symptoms/ FM treatment should be individualized Consider FM reevaluation in the future
comorbid conditions on the basis of symptoms/comorbid
Multimodal treatment conditions
Patient education
Support networks
Physical therapy/exercise,
psychological support
Pharmacological approaches
Develop long-term FM management
plan

After 3 to 4 mo, assess treatment response to evaluate whether treatment adjustments are needed
and/or whether additional differential diagnosis is needed to identify comorbid conditions

FIGURE 2. Flow chart for the diagnosis of fibromyalgia (FM). ACR = American College of Rheumatology; PE = physical examination; SS = Symp-
tom Severity; WPI = Widespread Pain Index.

462 Mayo Clin Proc. • May 2011;86(5):457-464 • doi:10.4065/mcp.2010.0738 • www.mayoclinicproceedings.com

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 Recognizing and diagnosing fibromyalgia

TABLE 2. Differentiating Selected Disorders From Fibromyalgiaa

Disorder Clinical presentation Typical characteristics Diagnostic testsb
Fibromyalgia Chronic widespread pain, sleep Female predominance (7-9:1c) ACR tender point examination
disturbance, fatigue, mood Onset: 25-60 y (may occur in Laboratory results typically within
symptoms, other somatic symptoms adolescents) normal limits
Prevalence: 2%-5% of adults
Myofascial pain Localized muscle pain arising No sex predominance Palpation of trigger points
syndrome from trigger points, muscle Onset: all ages
stiffness, sleep disturbance Prevalence: 45%-54% of adults
Osteoarthritis Stiffness, gelling, crepitus, joint pain Onset: increases with age Radiography
(knee, hip, hand) Prevalence: ~9% of adults DIP/PIP nodules
c
Hypothyroidism Weight gain, cold intolerance, Female predominance (2-8:1 ) Serum TSH
fatigue, muscle aches Prevalence: ~5% of adults
Rheumatoid arthritis Symmetric swelling of joints, Female predominance (2-3:1C) RF, anti-CCP, ESR, CRP, radiography
insidious onset, morning Onset: 30-50 y
stiffness (>1 h) Prevalence: ~0.5% to 1% of adults
Polymyalgia rheumatica Weakness, pain in girdle muscles Female predominance (2:1c) ESR, CRP, response to corticosteroids
(neck, shoulders, thighs), stiffness Onset: >50 y
Prevalence: ~0.2% of adults
Systemic lupus Photosensitivity, fever, rash, fatigue, Female predominance (9:1c) ANA, ESR, CRP, anti-DNA
erythematosus joint/muscle pain Onset: 16-55 y
Prevalence: ~0.05% of adults
Polymyositis Symmetric, proximal muscle Female predominance (2-3:1c) CPK, EMG
weakness and pain Onset: >20 y (especially 45-60 y)
Prevalence: ~0.005%-0.01% of adults
a
ACR = American College of Rheumatology; ANA = antinuclear antibody; anti-CCP = anticyclic citrullinated peptide antibody; CPK = creatine phospho-
kinase; CRP = C-reactive protein; DIP/PIP = distal interphalangeal/proximal interphalangeal; EMG = electromyography; ESR = erythrocyte sedimenta-
tion rate; RF = rheumatoid factor; TSH = thyroid-stimulating hormone.
b
No laboratory tests are required to establish the diagnosis of fibromyalgia.
c
Ratio of female to male patients.

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1. Wolfe F, Ross K, Anderson J, Russell IJ, Hebert L. The prevalence and
characteristics of fibromyalgia in the general population. Arthritis Rheum.
1995;38(1):19-28.
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Mayo Clin Proc. • May 2011;86(5):457-464 • doi:10.4065/mcp.2010.0738 • www.mayoclinicproceedings.com 463

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a Clinic Proceedings.
Recognizing and diagnosing fibromyalgia

28. Weir PT, Harlan GA, Nkoy FL, et al. The incidence of fibromyalgia and
its associated comorbidities: a population-based retrospective cohort study
Questions About Fibromyalgia
based on International Classification of Diseases, 9th Revision codes. J Clin
Rheumatol. 2006;12(3):124-128. 1. Which one of the following triad of symptoms is the
29. Arnold LM. The pathophysiology, diagnosis and treatment of fibromyal- most typical presentation of fibromyalgia (FM)?
gia. Psychiatr Clin North Am. 2010;33(2):375-408.
30. Goldenberg DL. Fibromyalgia syndrome a decade later: what have we a. Pain, anorexia, and elevated creatine phosphokinase
learned? Arch Intern Med. 1999;159(8):777-785. levels
31. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheu-
matology 1990 criteria for the classification of fibromyalgia: report of the Mul- b. Pain, mild dysphasia, and ataxia
ticenter Criteria Committee. Arthritis Rheum. 1990;33(2):160-172. c. Pain, disturbed sleep, and fatigue
32. Okifuji A, Turk DC, Sinclair JD, Starz TW, Marcus DA. A standardized d. Pain, paresthesia, and depression
manual tender point survey, I: Development and determination of a threshold
point for the identification of positive tender points in fibromyalgia syndrome.
e. Pain, swollen joints, and elevated erythrocyte sedi-
J Rheumatol. 1997;24(2):377-383. mentation rate
33. Harth M, Nielson WR. The fibromyalgia tender points: use them or lose 2. Which one of the following best describes the
them? a brief review of the controversy. J Rheumatol. 2007;34(5):914-922. pathophysiology of FM pain?
34. Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheu-
matology preliminary diagnostic criteria for fibromyalgia and measurement of a. Aberrant processing of painful stimuli in the central
symptom severity. Arthritis Care Res (Hoboken). 2010;62(5):600-610.
35. Yunus MB. A comprehensive medical evaluation of patients with fibro-
nervous system
myalgia syndrome. Rheum Dis Clin North Am. 2002;28(2):201-217, v-vi. b. Diffuse chronic inflammation of muscle tissue
c. Degeneration of muscle fibrous tissue
d. Neuronal damage by vitamin B12 deficiency
e. Excessive production of neurotransmitters in muscle
tissue
3. Which one of the following is not a risk factor for FM?
a. Family history of FM
b. Family history of rheumatoid arthritis
Additional Members of the FibroCollaborative. Kenneth Bar- c. History of trauma or injury
row, PA-C, MHS, Independence Back Institute, Wilmington, NC; d. History of abuse
Lucinda Bateman, MD, Fatigue Consultation Clinic Inc, Salt e. Sex
Lake City, UT; Larry Culpepper, MD, MPH, Boston University,
Boston, MA; Cassandra Curtis, MD, American Health Network,
4. Which one of the following laboratory tests is required
Greenfield, IN; Yvonne D’Arcy, MS, CRNP, CNS, Suburban Hos-
for FM diagnosis?
pital-Johns Hopkins Medicine, Bethesda, MD; L. Jean Dunegan, a. Rheumatoid factor
MD, JD, Hillsdale Community Health Center, Brighton, MI; Kev- b. Erythrocyte sedimentation rate
in B. Gebke, MD, Indiana University, Indianapolis; Robert Ger- c. C-reactive protein level
win, MD, Pain and Rehabilitation Medicine, Bethesda, MD; Don d. Iron-binding capacity
L. Goldenberg, MD, Newton-Wellesley Hospital, Newton, MA; e. No laboratory tests are required to establish the di-
James I. Hudson, MD, ScD, Harvard University, Belmont, MA; agnosis of FM
Rakesh Jain, MD, MPH, Clinical Research Center, Lake Jackson,
5. Which one of the following presentations should raise a
TX; Arnold L. Katz, MD, Overland Park Regional Medical Cen-

high index of suspicion for FM?
ter, Overland Park, KS; Andrew G. Kowal, MD, Tufts University,
Burlington, MA; Charles Lapp, MD, Duke University, Charlotte, a. Chronic pain at a specific site
NC; Philip J. Mease, MD, Swedish Medical Center, Seattle, WA; b. Swelling of multiple joints
Danielle Petersel, MD, Pfizer Inc, New York, NY; I. Jon Russell, c. A 1-week history of pain in multiple sites
MD, PhD, University of Texas, San Antonio; Stephen M. Stahl, d. Chronic widespread pain lasting 2 years
MD, PhD, University of California, San Diego; Dennis C. Turk, e. Symptoms of depression
PhD, University of Washington, Seattle; and Alvin F. Wells, MD,
PhD, Rheumatology & Immunotherapy Center, Oak Creek, WI. Correct answers: 1. c, 2. a, 3. b, 4. e, 5. d

464 Mayo Clin Proc. • May 2011;86(5):457-464 • doi:10.4065/mcp.2010.0738 • www.mayoclinicproceedings.com

For personal use. Mass reproduce only with permission from Mayo
a Clinic Proceedings.