Fibromyalgia

Fibromyalgia
Straight to the point of care
Last updated: Apr 09, 2021

Table of Contents
Overview 3
Summary 3
Definition 3
Theory 4
Epidemiology 4
Aetiology 4
Pathophysiology 4
Classification 5
Case history 6
Diagnosis 7
Approach 7
History and exam 7
Risk factors 8
Investigations 9
Differentials 11
Criteria 13
Management 15
Approach 15
Treatment algorithm overview 17
Treatment algorithm 18
Emerging 24
Patient discussions 25
Follow up 27
Prognosis 27
Guidelines 28
Diagnostic guidelines 28
Treatment guidelines 28
Online resources 30
References 31
Disclaimer 42
Fibromyalgia Overview
Summary
Patients typically present with chronic, widespread body pain and almost always have accompanying
comorbid symptoms such as fatigue, memory difficulties, and sleep and mood difficulties
OVERVIEW
Physical examination is typically normal but there is often diffuse tenderness, which may be assessed by
counting the number of tender points or by palpating several areas of the body.
Many therapies have been shown to be beneficial. Non-pharmacological therapies include patient education,
exercise, and cognitive behavioural approaches. Pharmacological therapies include tricyclic antidepressants,
gabapentinoids, and serotonin-noradrenaline (norepinephrine) reuptake inhibitors. Patients often fare better
when several different types of treatment are used together.
Even though practitioners may have a problem recognising fibromyalgia as a discrete disorder, they should
understand the diagnostic and therapeutic importance of 'centralisation' of pain as exemplified by a typical
fibromyalgia patient. When a patient with any chronic pain state develops evidence of centralisation of pain,
it is likely that treatments that work well for acute pain or pain primarily due to nociceptive input (NSAIDs,
opioids, anti-inflammatories, immunosuppressives, injections, surgical procedures) will be less effective.
Definition
Fibromyalgia is a chronic pain syndrome diagnosed by the presence of widespread body pain.
The 1990 American College of Rheumatology criteria for the classification of fibromyalgia required that an
individual had widespread pain (front and back, right and left, both sides of the diaphragm) for at least 3
months in addition to tenderness (digital palpation at an approximate force of 4 kg) of at least 11 out of 18
designated tender point sites.[1] Subsequent criteria do not require a tender point examination by performing
a tender point count, and focus on identifying widespread pain in combination with fatigue and memory and
sleep difficulties.[2] [3] [4] Although there is not likely to be any single cause, substantial evidence suggests
that this is in part a central nervous system-driven pain amplification syndrome.
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Fibromyalgia Theory
Epidemiology
Fibromyalgia is a common condition worldwide in all ethnic and socio-economic groups.[7] [8] [9] [10] [11]
Studies show the prevalence in the general population to be between 0.5% and 5%.[9]
THEORY
In the US, the overall prevalence, using the 1990 American College of Rheumatology criteria, is around
2%.[10] The prevalence is higher in women (3.5%) than in men (0.5%), and 9 out of 10 patients with
fibromyalgia are female.[10] This bias towards diagnosing almost exclusively females is related to the 1990
fibromyalgia criteria requiring a certain number of tender points (women are inherently more tender than
men, so many more will meet these criteria).
Subsequent criteria do not have such a strong female predominance and diagnose many more males.[4] [12]
An increase in the prevalence of fibromyalgia to between 6% and 8% of the population has been reported.[4]
[12] [13]
Age of onset is typically between 20 and 60 years, with an average age of 35 years. Prevalence increases
with age.[9] [10] Fibromyalgia can also present in childhood. Familial and genetic factors play an extremely
strong role; first-degree relatives of individuals with fibromyalgia are eight times more likely to have the
condition.[14]
Aetiology
Fibromyalgia is one of many chronic pain disorders that co-aggregate strongly in individuals and families,
including irritable bowel syndrome, temporomandibular joint disorder, interstitial cystitis, vulvodynia, and
tension headaches. The preferred terms for these conditions are 'central sensitisation syndrome' and
chronic overlapping pain conditions (COPCs). The underlying mechanism of pain originating from the central
nervous system is now referred to as nociplastic pain. Individuals will sometimes only have one of these
'idiopathic' pain syndromes over the course of their lifetime; but more often, people with one of these entities,
and their family members, are likely to have several of these conditions.[14] [15] A variety of chronic pain
conditions are highly familial, and specific genetic polymorphisms that increase or decrease pain processing
are rapidly being identified.[16] [17] [18]
Some patients may have comorbid psychiatric conditions, but at any given time most do not. A number of
studies demonstrate that these pain syndromes differ and are separable from depression and anxiety, and
have strong genetic underpinnings.[19] [20] [21] [22] Women are more likely to have these disorders than
men (approximately 1.5 times as likely), but the sex difference is much more pronounced in fibromyalgia than
in other chronic pain conditions because of unintended consequences of requiring a certain number of tender
points in the 1990 American College of Rheumatology criteria. Also, clinical samples (especially in tertiary
care) tend to over-represent females compared with population-based samples.[23] [24]
Pathophysiology
It is widely agreed that the primary 'pathology' in these illnesses is in the central nervous system (i.e.,
brain and spinal cord) and involves pain and/or sensory amplification. A hallmark of these conditions (e.g.,
fibromyalgia, irritable bowel syndrome, headache, temporomandibular joint disorder) is that individuals
display diffuse hyperalgesia (increased pain in response to normally painful stimuli) and/or allodynia (pain in
response to normally non-painful stimuli).[25] [26] [27] [28] [29] [30] This suggests a fundamental problem
with augmented pain or sensory processing (i.e., an increase gain setting) in the central nervous system
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Apr 09, 2021.
Fibromyalgia Theory
(CNS), rather than a pathological abnormality confined to the region of the body where the person is
currently experiencing pain.
These findings of 'centralisation' of pain can be corroborated by the presence of these same phenomena on
THEORY
functional neuroimaging studies, and appear to be in part due to imbalances in levels of neurotransmitters
that affect pain and sensory transmission. Because of this, CNS-mediated symptoms other than pain
(fatigue, memory difficulties, sleep and mood disorders) are frequent comorbidities.
Similar types of therapy are efficacious for all of these conditions, including both pharmacological
treatments (e.g., drugs that raise anti-nociceptive neurotransmitters such as serotonin and noradrenaline
[norepinephrine], or lower pro-nociceptive neurotransmitters such as glutamate, substance P) and non-
pharmacological treatments (e.g., exercise, cognitive behavioural therapy).
Some studies suggest that the small fibres of peripheral nerves may be abnormal (i.e., decreased
number, increased tortuosity) in some individuals with fibromyalgia, or that there may be structural
abnormalities of the brain.[31] [32] [33] These studies are aligned with others in the pain field suggesting
that chronic pain may be associated with significant neuroplasticity.[34] Many groups have used either voxel-
based morphometry or diffuse tensor imaging to identify abnormalities in brain structure in people with
fibromyalgia.[35] [36] [37] [38] [39] In the largest such study, some of these abnormalities may have been due
to frequently comorbid psychiatric conditions that are known to demonstrate the same changes.[40] Thus,
if there are structural abnormalities or damage to tissues in fibromyalgia, most evidence for this is involving
neural tissues rather than the regions of the body where people with this condition experience pain.
Classification
Clinical classifications
1. Primary fibromyalgia is the more common form of fibromyalgia, whereby another cause for pain is not
found.[5]
2. Secondary or concomitant fibromyalgia is sometimes used to refer to fibromyalgia that accompanies
another painful disorder or follows an inciting event.[5] Some recommend against using this
designation because there is no evidence that the pathophysiology is different in these patients, except
that treating the root problem (e.g., a comorbid rheumatic disease or 'peripheral pain generator') can
sometimes make the fibromyalgia itself better.
Stressors that may incite fibromyalgia include:
• Significant infection (e.g., Epstein-Barr virus [EBV] infection, Lyme disease)

• Injury, physical trauma such as motor vehicle collision
• Emotional trauma or war deployment
• Major surgical procedures
• Peripheral pain syndrome such as osteoarthritis, rheumatoid arthritis.
Inciting events are not felt to be necessarily causal per se, but may trigger pain amplification and
'centralisation/chronification', resulting in the symptoms of fibromyalgia.
3. Juvenile fibromyalgia is a much less common form of the condition, which occurs in children and
adolescents.[6] It may carry a slightly better prognosis than fibromyalgia in adults; in some cases the
condition spontaneously remits.
5
Fibromyalgia Theory
Case history
Case history #1
THEORY
A 38-year-old woman sees her physician with 4 years of widespread body pain. The pain began after a
motor vehicle accident and was initially limited to her neck. Gradually, the pain has spread and she now
complains of hurting all over, all the time. She does not have any joint swelling or systemic symptoms.
She does not sleep well and has fatigue. She has irritable bowel syndrome but is otherwise healthy.
Physical examination reveals a well-appearing woman with normal musculoskeletal examination, except
for diffuse tenderness to palpation. Routine laboratory testing is normal.
Other presentations
Chronic, widespread pain, which is ultimately diagnosed as fibromyalgia, often begins following a
significant injury, trauma, illness, admission to hospital, or emotionally stressful period, but an inciting
event is not always seen.
Fibromyalgia often co-exists with other rheumatological conditions, such as rheumatoid arthritis, systemic
lupus erythematosus (SLE), and osteoarthritis; importantly, the presence of these conditions does
not exclude a concomitant diagnosis of fibromyalgia (i.e., fibromyalgia is not a diagnosis of exclusion).
Patients with fibromyalgia often have co-existent depression and anxiety at a higher frequency than
patients without the disease, but mental illness is not a pre-requisite for its diagnosis.
Fibromyalgia Diagnosis
Approach
The diagnosis of fibromyalgia should be considered when a person presents with chronic multi-focal pain for
longer than 3 months, especially if other symptoms such as fatigue, memory problems, and sleep and mood
disturbances are noted, together with a normal physical examination.
The diagnosis is more likely if the patient has a family and/or lifetime history or multiple other episodes of
chronic pain, and if there are also symptoms or signs of sensory sensitivity, such as undue sensitivity to
touch or light clothing; to light, noises, or odours; or tenderness to palpation in multiple body regions.
History
According to the 2010 American College of Rheumatology (ACR) preliminary diagnostic criteria, a
diagnosis of fibromyalgia requires the presence of widespread body pain for at least 3 months.[2]
Widespread body pain is defined as axial pain plus upper and lower segment plus left- and right-
sided pain. Pain may be myalgia, arthralgia, or both. The pain of fibromyalgia is often described using
'neuropathic' descriptors such as gnawing, lancinating, or accompanied by numbness or tingling. While
other conditions such as irritable bowel syndrome, headaches, mood disorders, and interstitial cystitis
are found in increased frequency in patients with fibromyalgia, the presence of these conditions is not
required for the diagnosis. Additional symptoms typically include fatigue, sleep problems, memory
problems, and stiffness.
Physical examination
The criteria for fibromyalgia as set forth by the ACR in 1990 included excess tenderness to palpation in
at least 11 of 18 defined tender points.[1] The examiner should apply enough pressure to these tender
points such that his or her nail bed blanches. Unless there is a comorbid rheumatological condition,
the remainder of the musculoskeletal examination is normal. However, most clinicians have not been
trained in this tender point examination and diagnostic criteria have been established that do not require
performing a tender point count.[2] These criteria consist of adding up the number of body sites of pain
as well as the presence and severity of frequent comorbid symptoms such as fatigue, memory problems,
and sleep disturbances.
DIAGNOSIS
Diagnostic testing
There is no x-ray or laboratory test for fibromyalgia; the diagnosis is strictly a clinical one.[46]
If the patient does not meet clinical criteria for a diagnosis of fibromyalgia, then some tests, including
full blood count, thyroid function tests, erythrocyte sedimentation rate and CRP, and vitamin D levels,
should be performed to screen for alternative causes of symptoms. Rheumatoid factor (RF), anti-cyclic
citrullinated protein antibody (anti-CCP antibody), and antinuclear antibody may be obtained if patients
have a history suggestive of an inflammatory disorder. These tests are not routinely recommended during
testing for fibromyalgia. False positives may occur; positive results indicate the presence of another
disorder, but they do not rule out fibromyalgia.
History and exam

Key diagnostic factors
chronic pain (common)
7
• Chronic, widespread body pain is necessary for diagnosis.
diffuse tenderness on examination (common)

• Patients exhibit diffuse tenderness to palpation on physical examination. There is no evidence for a
systemic disease (e.g., joint inflammation or muscle weakness) causing the widespread pain.
Other diagnostic factors

fatigue unrelieved by rest (common)
• Most patients (>90%) report significant fatigue.
sleep disturbance (common)

• Commonly reported by patients.
• Unless there is reason to suspect a primary sleep disorder, such as obstructive sleep apnoea or
restless legs syndrome, a sleep study is not recommended.
mood disturbance (common)

• Lifetime incidence of depression and/or anxiety in patients with fibromyalgia is much higher than in
patients without the disorder (74% and 60%, respectively); 30% of patients meet criteria for major
depression at diagnosis.[47]
cognitive dysfunction (common)

• Subjectively reported by many patients, but whether this is a primary manifestation of fibromyalgia or
related to poor sleep is unknown.
headaches (common)
• Pain tends to be axial in nature and may extend into neck and shoulders.
numbness/tingling sensations (common)

• May be concomitant with pain and variable in nature and duration.
DIAGNOSIS
stiffness (common)
• May be accompanied by a sensation of swelling without physical evidence of same.
sensitivity to sensory stimuli such as bright lights, odours, noises (common)

• Patients may have symptoms and signs of undue sensory sensitivity, including sensitivity to touch or
wearing tight clothing; sensitivity to light, noises, or odours; or tenderness to palpation in multiple body
regions.
Risk factors
Strong
family history of fibromyalgia
• The rate of fibromyalgia in the general adult population is around 2% to 8%.[4] [12] [41]
Epidemiological studies have found that the rate in relatives of patients with fibromyalgia is much
higher, perhaps as high as 41%.[42] However, experts acknowledge that the contribution of
environmental factors to the increased prevalence of fibromyalgia in families cannot be ruled out.
• Abnormalities in serotonergic, dopaminergic, and catecholaminergic genes are found at higher
frequency in patients with fibromyalgia than in normal controls.[43] These findings have therapeutic
implications for treatment of fibromyalgia.
rheumatological conditions
• Although there is no evidence that fibromyalgia is an autoimmune condition, patients with autoimmune
rheumatological conditions (e.g., rheumatoid arthritis, systemic lupus erythematosus) or chronic
pain conditions (e.g., osteoarthritis) have a much higher prevalence of fibromyalgia than the general
population.
• Approximately 15% to 30% of patients with nearly any autoimmune disorder will also meet criteria for
fibromyalgia. When this occurs these patients need to be recognised and treated for both peripheral
and central causes of pain.[44]
age between 20 and 60 years

• Presents between the ages of 20 and 60 years, with a peak age of onset of around 30 years old.
• Prevalence increases with age.[10] [45]
female sex
• More commonly seen in females than males, with a ratio of approximately 9:1 using the 1990
American College of Rheumatology criteria.
• Subsequent criteria do not have such a strong female predominance and diagnose many more
males.[4] [12]
Weak
presence of associated conditions
• Most patients with fibromyalgia meet criteria for associated or allied conditions such as irritable bowel
syndrome, tension headache, chronic fatigue syndrome, temporomandibular joint disorder, and
DIAGNOSIS
interstitial cystitis.
Investigations
1st test to order
Test Result
clinical diagnosis presence of chronic (>3
months), widespread
• There is no x-ray or laboratory testing for fibromyalgia; the diagnosis
body pain and associated
is strictly clinical.
symptoms such as fatigue
• If the patient does not meet clinical criteria for a diagnosis of
and sleep disturbance
fibromyalgia, then some further tests may help explain the patient's
musculoskeletal pain or fatigue.
9
Other tests to consider
Test Result
erythrocyte sedimentation rate/CRP likely to be normal
• To exclude inflammatory cause of muscular pain or fatigue.
thyroid function test likely to be normal
• To exclude hypothyroidism.
FBC likely to be normal
• To exclude anaemia as a cause for fatigue or iron deficiency as a
cause for muscle pain and fatigue.
rheumatoid factor likely to be normal
• To exclude rheumatoid arthritis; indicated only if true arthritis is
present; not recommended for routine testing of fibromyalgia because
it has many false-positive results.
anti-cyclic citrullinated protein (CCP) antibody likely to be normal
• To exclude rheumatoid arthritis; indicted only if true arthritis is
antinuclear antibody likely to be normal
• To exclude systemic lupus erythematosus (SLE).
• Indicated only if true arthritis or other signs or symptoms of SLE are
vitamin D level likely to be normal
• To exclude vitamin D deficiency as a cause for widespread muscular
pain.
DIAGNOSIS
Differentials
Condition Differentiating signs / Differentiating tests

symptoms
Myofascial pain syndrome • Myalgia is localised, • Patients with localised
(MPS) typically to an extremity MPS do not have evidence
and the attached truncal of widespread central
musculature. sensitisation.
• In contrast to the tender
points of fibromyalgia, trigger
points are the hallmark
of MPS, with pressure
over these areas not only
reported as tender but
causing radiation and
reproduction of the pain.
• Some experts consider MPS
to be a localised form of
fibromyalgia.
Vitamin D deficiency • Low vitamin D levels are • Serum 25-hydroxyvitamin D

associated with widespread level is low.
body pain; however, this
may not be causal but
may instead be due to low
outdoor activity and sunlight
exposure in people with
chronic pain.
Chronic fatigue syndrome • There is considerable • No differentiating tests.

(CFS) overlap between fibromyalgia
and CFS, with most patients
with fibromyalgia meeting
criteria for CFS, and most
DIAGNOSIS
CFS patients reporting
widespread body pain.[19]
Rheumatoid arthritis (RA) • As with other • RF or anti-cyclic citrullinated

rheumatological conditions, protein (CCP) antibody is
fibromyalgia may co- usually positive.
exist with RA, making the • Markers of systemic
diagnosis challenging. inflammation (erythrocyte
• Patients with RA will have sedimentation rate, CRP) are
not only widespread body typically elevated.
pain and arthralgias but
should also have signs of
active synovitis on physical
examination.
• If a patient with RA also
has widespread pain and
soft-tissue tenderness,
fibromyalgia is likely. If the
patient is treated for RA with
subsequent resolution of
synovitis and markers of
inflammation, yet the patient
11

symptoms
still has widespread pain and
fatigue, the most likely cause
is fibromyalgia.
Systemic lupus • SLE and fibromyalgia may • Strict criteria for the
erythematosus (SLE) co-exist. diagnosis of SLE must be
met; an isolated positive
antinuclear antibody
(ANA) test is not enough
to establish the diagnosis
of SLE in a patient with
widespread pain as ANA is
positive in up to 10% of the
general population.
Osteoarthritis • Joint swelling and • X-rays are characteristic:

inflammation are common joint space narrowing,
in osteoarthritis, but not in subchondral sclerosis,
fibromyalgia unless it is a osteophytes, subchondral
concomitant diagnosis. cysts.
Ank ylosing spondylitis • Patients have limited • X-ray features are

range of movement of the characteristic: erosions
spine; spine movement and osteitis at the ischial
in fibromyalgia is typically tuberosities, iliac crest,
maintained. symphysis pubis, and
femoral trochanter.
Polymyalgia rheumatica • Patients are typically older • Erythrocyte sedimentation

(PMR) (>55 years of age) on rate, CRP, or other markers
presentation than those with of inflammation are usually
fibromyalgia. elevated.
• PMR is associated with hip
and shoulder girdle pain
DIAGNOSIS
but also with significant

weakness and stiffness.
• PMR typically responds
extremely well to
corticosteroids, whereas
patients with fibromyalgia
will not improve with
corticosteroid treatment.
Hypothyroidism • Patients with hypothyroidism • TSH is elevated and free T4

may have muscular aching is low.
and prominent fatigue that
improves on replacement of
thyroid hormone.
• A routine thyroid-stimulating
hormone (TSH) test is
recommended for patients
presenting with suspicion of
fibromyalgia. Fibromyalgia
and hypothyroidism may co-
exist.

symptoms
Myositis • Weakness and muscle • Creatine kinase or aldolase
(dermatomyositis and fatigue are present (and levels are elevated.
other inflammatory more common than pain)
myopathies) in patients with a primary
muscle inflammatory
condition.
Chronic liver disease • Patients with liver disease, • Elevated liver function tests;
most notably hepatitis C, presence of hepatitis C
often have myalgias. antibody.
Iron deficiency anaemia • Patients with myalgias and • Low serum iron levels, low
iron deficiency often report transferrin saturation.
improvement in symptoms
with iron replacement.
Criteria
American College of Rheumatology (ACR) 1990 criteria for the
classification of fibromyalgia[1]
The presence of chronic (>3 months), widespread (axial plus upper and lower segment plus left- and right-
side) body pain in the muscles and joints, plus at least 11 of 18 tender points, positively establishes the
diagnosis of fibromyalgia (81% sensitivity, 88% specificity).
ACR 2010 preliminary diagnostic criteria for fibromyalgia and

measurement of symptom severity[2]
DIAGNOSIS
Criteria have been established that do not require performing a tender point count. These criteria consist
of adding up the number of body sites of pain as well as the presence and severity of frequent comorbid
symptoms such as fatigue, memory problems, and sleep disturbances.
Fibromyalgia criteria and severity scales for clinical and

epidemiological studies: a modification of the ACR preliminary
diagnostic criteria for fibromyalgia[4]
Modified ACR 2010 criteria that include a new Fibromyalgia Symptom scale (FS) formed by the combination
of the Widespread Pain Index (WPI) and Symptom Severity score (SS). The modified ACR 2010 criteria
enable diagnosis to be accomplished entirely by self-report.
ACTTION-APS Pain Taxonomy (AAPT) diagnostic criteria for

fibromyalgia[48]
Utilises the multidimensional diagnostic framework adopted by AAPT. Core diagnostic criteria are:
1. Multi-site pain defined as 6 or more pain sites from a total of 9 possible sites
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2. Moderate to severe sleep problems OR fatigue
3. Multi-site pain plus fatigue or sleep problems must have been present for at least 3 months.
2016 revisions to the 2010/2011 American College of Rheumatology

(ACR) criteria for fibromyalgia syndrome[3]
In 2016, revised criteria were developed, based on the 2010 ACR criteria and the 2011 self-reported survey
questionnaire. The criteria include:
1. Generalised pain, defined as pain in at least 4 of 5 regions.

2. Symptoms have been present at a similar level for at least 3 months.
3. Widespread Pain Index (WPI) ≥7 and symptom severity scale (SSS) score ≥ 5 or WPI 4-6 and SSS
score ≥ 9.
4. A diagnosis of fibromyalgia is valid irrespective of other diagnosis. A diagnosis of fibromyalgia does not
exclude the presence of other clinically important illnesses.
DIAGNOSIS
Fibromyalgia Management
Approach
Fibromyalgia can be managed but not cured. Most patients can function reasonably well if they play an active
role in their therapy, which is likely to contain a combination of drug and non-drug therapies.
Often, initiating pharmacological therapy prior to non-pharmacological therapy is helpful because patients
may be more compliant with exercise and cognitive behavioural techniques if their symptoms are improved
by medications.
Overview of management
The classes of drugs with the most evidence of efficacy include tricyclic antidepressants (TCAs) (e.g.,
amitriptyline, cyclobenzaprine), serotonin-noradrenaline reuptake inhibitors (SNRIs) (e.g., duloxetine,
milnacipran), and gabapentinoids (e.g., pregabalin, gabapentin). Often patients will benefit from two or
three drug classes used together, whereas other patients respond to only one class of drug.[49] The
overall efficacy of the current drugs for fibromyalgia is comparable to pharmacological therapy for other
chronic pain states.[50]
All patients should probably be tried on one or two TCAs first, because these drugs are inexpensive and,
when they do work, often improve sleep and visceral motility as well as pain. An SNRI is a good first
choice when the patient suffers from comorbid depression or fatigue, whereas a gabapentinoid may be
preferred when the individual is experiencing significant comorbid sleep issues (especially if these drugs
are only administered at bedtime - or with a higher proportion of the dose at bedtime).
Once the patient has noted some improvement in symptoms with pharmacological therapies, the clinician
should advocate for the use of non-pharmacological therapies.
Using this approach, most patients with fibromyalgia note a significant improvement and can continue
to function normally. Some individuals, especially those with long-standing symptoms and functional
consequences (e.g., disability, compensation), those on high-dose opioids, those with significant
psychiatric comorbidities, and those who have had multiple 'failed' surgical procedures, will not respond to
this approach and will need inter-disciplinary care.
Antidepressants
The serotonin-noradrenaline reuptake inhibitors (SNRIs) duloxetine and milnacipran are effective in the
treatment of fibromyalgia.[51] But all patients should probably be tried on one or two TCAs first.
It should be noted that the efficacy of antidepressants in fibromyalgia seems to be independent of their
antidepressant effects, and not all antidepressants are effective against pain or in fibromyalgia.[52]
Moreover, it appears as though noradrenaline (norepinephrine) is the more important of the two
neurotransmitters involved in chronic pain, as the selective-noradrenaline reuptake inhibitor reboxetine
(only available as an investigational drug in the US) has been shown to be effective in the treatment of
fibromyalgia, whereas selective serotonin-reuptake inhibitors (SSRIs) have not been shown to be effective
in pre-clinical or clinical chronic pain conditions.[53] However, there have been some reports that using an
MANAGEMENT
SSRI together with a tricyclic antidepressant can be helpful in fibromyalgia.[54]
Tricyclic antidepressants (TCAs)
Meta-analyses suggest that a meaningful clinical response can be expected in about 30% of patients.[55]
[56] [57] However, there is no good evidence showing extension of benefit beyond 8 weeks.[58] If no
15
benefit is seen after a trial of 6 weeks, the medication can be stopped. If the medication was initially
effective but seems to have decreased efficacy, it can be temporarily discontinued and restarted.
The anticholinergic side effects of tricyclics often limit their tolerability, especially in older patients;
however, one benefit is that they can improve sleep.
SNRIs
Milnacipran has shown reduction in weekly pain scores compared with placebo.[59] [60] [61] [62] [63] A
>50% reduction in average pain levels can be expected in 40% of women treated with duloxetine for up
to 12 weeks.[64] The duloxetine risk/benefit profile appears to be favourable for at least 12 months for the
management of fibromyalgia.[64]
Tolerability of these drugs can be increased by warning patients of the risk of nausea and assuring
them that in most cases this is transient, and by starting the drugs at a low dose and increasing the
dose slowly. Gastrointestinal distress, hyperhidrosis, and headache are the most commonly reported
adverse effects with milnacipran.[59] [63] [65] The most common side effects of duloxetine are nausea
and headache.[66] [67]
Concomitant SNRI and TCA
SNRIs and tricyclics may be used together (e.g., the SNRI given in the morning, with the tricyclic given at
night); however, there is a risk of serotonin syndrome (considered rare in clinical practice) associated with
using these two drug classes together.
Gabapentinoids
Pregabalin is approved for fibromyalgia. Gabapentin is similarly effective, but is not approved for the
management of this condition.[68]
These drugs have analgesic properties as well as anxiolytic and anticonvulsant activity.[69] Meta-
analyses support use of either of these agents, reporting pain reduction, improved sleep, and improved
health-related quality of life.[70] [71]
The adverse-effect profiles of pregabalin and gabapentin are not significantly different. Tolerability is often
better if a higher proportion of the dose (or the entire dose) is given at bedtime.
Analgesia
There is no evidence that non-steroidal anti-inflammatory drugs (NSAIDs) and opioids are effective in
fibromyalgia.[72] [73] However, an NSAID (e.g., naproxen) may be beneficial in the setting of fibromyalgia
with a comorbid condition such as osteoarthritis, where there is ongoing peripheral nociceptive input.
A weak opioid, tramadol, has been useful in short-term studies.[74] However, there is no evidence that
stronger opioids are effective, and they should not be prescribed for long-term use in fibromyalgia.
Concern that these patients may be at increased risk of opioid-induced hyperalgesia may be largely
anecdotal.
MANAGEMENT
The use of NSAIDs and opioids in fibromyalgia is widespread, despite recommendations against their
use.[75]
Non-pharmacological therapies
Non-pharmacological therapies should be a key component in the overall treatment of fibromyalgia, but
are often under-utilised in clinical practice.
Consistently effective interventions include patient and family education, cognitive behavioural therapies
(CBT), and exercise.[76] [77] [78] Internet-based programmes incorporating education, CBT, biofeedback,
and exercise can be effective in fibromyalgia, particularly for those patients unable to access personal or
group provision of CBT.[79] Psychoeducational interventions may be very cost-effective compared with
other approaches.[80]
Derangement of the autonomic nervous system has been proposed to account for some of the
symptomatology in patients with fibromyalgia. Heart rate variability (HRV) biofeedback training, which
teaches the patient to breathe at a resonant frequency, can help decrease sympathetic overdrive and
perhaps reduce pain. There is a very small amount of evidence to suggest that there was decrease
in pain and depression and increase in functioning after 10 weekly sessions of HRV biofeedback
training.[81] Electromyography (EMG) biofeedback has been shown to be modestly helpful in decreasing
pain in a small study of poor design.[82] Further research is warranted.
Many types of therapy that combine exercise and relaxation (e.g., yoga, T'ai Chi, and aquatic exercise)
have also been shown to be helpful.[78] [83] [84]
There is insufficient high-quality evidence to support or refute the use of transcutaneous electrical nerve
stimulation (TENS) for fibromyalgia.[85]
Referral
Referral to a psychologist is appropriate at initial diagnosis.
Treatment algorithm overview

Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Ongoing ( summary )
all patients
1st pharmacotherapy
plus non-pharmacological therapies
adjunct analgesics
adjunct interdisciplinary care

MANAGEMENT
17
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
MANAGEMENT
Ongoing
all patients
1st pharmacotherapy
Primary options
» amitriptyline: 10-70 mg orally once daily at

bedtime
OR
» cyclobenzaprine: 5-30 mg orally once daily

at bedtime
Secondary options
» duloxetine: 30-60 mg orally once daily;

higher doses have been used, consult
specialist for guidance
OR
» milnacipran: 12.5 mg orally once daily

initially, followed by 12.5 mg twice daily for
2 days, followed by 25 mg twice daily for 4
days, then 50-100 mg twice daily thereafter
OR
» pregabalin: 75-225 mg orally twice daily,

maximum 450 mg/day
OR
» gabapentin: 300 mg orally once daily on

first day, followed by 300 mg twice daily on
second day, followed by 300 mg three times
daily on third day, then titrate dose according
to response up to 1800-2400 mg/day given in
3 divided doses
Tertiary options
» amitriptyline: 10-70 mg orally once daily at

bedtime
-or-
» cyclobenzaprine: 5-30 mg orally once daily
at bedtime
--AND/OR--
» duloxetine: 30-60 mg orally once daily;
MANAGEMENT
higher doses have been used, consult

specialist for guidance
-or-
» milnacipran: 12.5 mg orally once daily
initially, followed by 12.5 mg twice daily for
19
Ongoing
2 days, followed by 25 mg twice daily for 4
days, then 50-100 mg twice daily thereafter
--AND/OR--
» pregabalin: 75-225 mg orally twice daily,
maximum 450 mg/day
-or-
» gabapentin: 300 mg orally once daily on
first day, followed by 300 mg twice daily on
second day, followed by 300 mg three times
daily on third day, then titrate dose according
to response up to 1800-2400 mg/day given in
3 divided doses
» Drug classes with the most evidence

of efficacy are tricyclic antidepressants
(TCAs) (e.g., amitriptyline, cyclobenzaprine),
serotonin-noradrenaline reuptake inhibitors
(also known as serotonin-norepinephrine
reuptake inhibitors, or SNRIs) (e.g., duloxetine,
milnacipran), and gabapentinoids (e.g.,
pregabalin, gabapentin).[51] Often patients
benefit from two or three drug classes used
together, whereas other patients respond to (or
need) only one class.
» All patients should probably be tried on one

or two TCAs first, because these drugs are
inexpensive and can often improve sleep and
visceral motility as well as pain. Meaningful
clinical response can be expected in about
30% of patients.[55] [56] [57] However, benefits
do not seem to persist beyond 8 weeks.[58] If
no benefit is seen after a trial of 6 weeks, the
medication can be stopped. If the medication
was initially effective but then loses efficacy,
it can be temporarily discontinued and then
restarted.
» An SNRI is a good first choice for patients with

comorbid depression or fatigue. The benefits
and tolerability of SNRIs are maintained in
patients up to at least 1 year.[64] A >50%
reduction in average pain levels can be expected
in 40% of women treated with duloxetine for
up to 12 weeks.[64] Milnacipran has shown
reduction in weekly pain scores compared
with placebo.[59] [60] [61] [62] [63] SNRIs and
tricyclics may be used together (e.g., the SNRI
given in the morning, with the tricyclic given at
night); however, combining these drug classes
carries a risk (albeit rare) of serotonin syndrome.
MANAGEMENT
» A gabapentinoid may be a better first choice

for a patient with significant comorbid sleep
issues. Tolerability is often better if a higher
proportion of the dose (or the entire dose)
is given at bedtime. Pregabalin is approved
Ongoing
for this indication; however, gabapentin has
shown similar efficacy.[68] Meta-analyses have
supported use of either of these medications,
citing benefits in pain reduction, improved sleep,
and improved health-related quality of life.[70]
[71]
» Caution should be used when prescribing

combinations of drug classes, and a specialist
should be consulted for guidance on appropriate
combination regimens.
plus non-pharmacological therapies
Treatment recommended for ALL patients in
selected patient group
» Once the patient has noted some improvement
in symptoms with pharmacological therapies,
the clinician should advocate for the use
of non-pharmacological therapies, such as
education, exercise, and cognitive behavioural
approaches.[78] Many types of therapy that
combine exercise and relaxation, such as
yoga and T'ai Chi, have also been shown to be
helpful.[83]
» It is very important to educate the patient

about his or her condition, emphasising that
fibromyalgia can be managed but not cured, and
that most patients can function reasonably well if
they play an active role in their therapy, which is
likely to contain a combination of drug and non-
drug therapies.
» While the treatment of depression and anxiety

seems obvious to most clinicians, cognitive
behavioural therapy (CBT) and biofeedback
are specific techniques that demonstrate effect
sizes often greater than those for many of the
pharmacological treatments.
» Derangement of the autonomic nervous

system has been proposed to account for
some of the symptomatology in patients with
fibromyalgia. Heart rate variability (HRV)
biofeedback training, which teaches the
patient to breathe at a resonant frequency,
can help decrease sympathetic overdrive and
perhaps reduce pain. There is a very small
amount of evidence to suggest that there was
decrease in pain and depression and increase
in functioning after 10 weekly sessions of HRV
MANAGEMENT
biofeedback training.[81] Electromyography

(EMG) biofeedback has been shown to be
modestly helpful in decreasing pain in a small
study of poor design.[82] Further research is
warranted.
21
Ongoing
» These techniques are not offered by all
psychiatrists and psychologists, and many
patients cannot find trained providers. Because
of this, many groups are moving towards
showing that internet-based programmes
incorporating education, CBT, and exercise can
be effective in fibromyalgia and other chronic
pain states.[79]
adjunct analgesics
Treatment recommended for SOME patients in
Primary options
» naproxen: 500 mg orally initially, followed

by 250 mg every 6-8 hours when required,
maximum 1250 mg/day
OR
» tramadol: 50 mg orally (immediate-release)

every 4-6 hours when required, maximum
400 mg/day
» Although non-steroidal anti-inflammatory

drugs (NSAIDs) and opioids are highly effective
for acute pain, and are also among the first-
line treatments for long-standing nociceptive
pain states (i.e., conditions in which the pain
is caused primarily by damage to peripheral
tissue), there is no evidence that they are
effective alone in fibromyalgia.[72] [73]
» However, in the setting of fibromyalgia with

a comorbid condition such as osteoarthritis in
which there is ongoing peripheral nociceptive
input, it may be useful to use an NSAID (e.g.,
naproxen). A weak opioid, tramadol, has been
useful in short-term studies, but there is no
evidence that stronger opioids are effective,
and they should not be prescribed for long-term
use in fibromyalgia.[74] Despite the general
recommendation against the use of these agents
in fibromyalgia, as well as the (largely anecdotal)
concern that these patients may be at increased
risk of opioid-induced hyperalgesia, their use is
still widespread.
adjunct interdisciplinary care
Treatment recommended for SOME patients in
MANAGEMENT
» Referral to a psychologist is appropriate at

initial diagnosis. In addition, although most
patients note a significant improvement with
pharmacotherapy and non-pharmacological
approaches such as additional individual
Ongoing
and family education, exercise, and cognitive
behavioural therapy, some patients (especially
those with long-standing symptoms and
functional consequences such as disability
or compensation issues, those on high-dose
opioids, those with significant psychiatric
comorbidities, and those who have had multiple
'failed' surgical procedures) will not respond
to these approaches and will need further
interdisciplinary care.
MANAGEMENT
23
Emerging
Central neurostimulatory therapies
An exciting development in the pain field that is being partially led by work in fibromyalgia is the explosion
of interest and knowledge in the use of central neurostimulatory therapies in fibromyalgia and related
conditions.[86] [87] These therapies, which include transcranial direct current stimulation and magnetic
stimulation, have been shown to have impressive effects on pain and a number of other domains in
fibromyalgia, and in some cases the effect of therapy has lasted well after the cessation of treatment.[88]
Esreboxetine
A highly selective noradrenaline (norepinephrine) reuptake inhibitor that has been studied in pre-clinical
pain models and is being investigated for use in fibromyalgia. A blinded, placebo-controlled study of 267
patients showed that the esreboxetine group had statistically significant improvement compared with placebo
with respect to weekly average pain, and that more patients in the treatment group reported a >30% pain
reduction (37.6% vs. 22.4%). Improvements were also seen in quality of life and functional measures.[53]
Manual therapies
There is moderate evidence for massage therapy and limited evidence of poor quality for spinal manipulation
to help patients with fibromyalgia.[89] [90] [91] [92]
Vagus nerve stimulation (VNS)

Further research is planned into VNS, which has been shown to be efficacious in laboratory models to
reduce pain. Research will involve implantation of a VNS unit in patients with refractory fibromyalgia.[93]
Acupuncture
Trials of acupuncture for fibromyalgia have conflicting results.[94] [95] One review suggested that
acupuncture should be considered for patients who have not responded to other therapies, as it is not known
to be harmful; however, another review concluded that there was no substantial evidence for the use of
acupuncture for pain reduction in this patient population.[96] [97] A review of randomised trials of traditional
Chinese medicine (TCM) treatment for fibromyalgia (including not only acupuncture but also TCM modalities
of herbal medication and cupping) suggested that these therapies seem to be effective, but trials are limited
by insufficient methodological rigour.[98]
Homeopathy
A systematic review on trials of homoeopathy for symptom reduction in fibromyalgia found 3 placebo-
controlled randomised controlled trials that suggested benefit from the use of homeopathy, although more
research is needed.[99]
Herbal/supplement medications
Studies suggest potential benefit from magnesium, l-carnitine, and S-adenosylmethionine, although firm
conclusions cannot yet be drawn on the benefits of these or other supplements.[100]
Sodium ox ybate
MANAGEMENT
Sodium oxybate (also known as gamma-hydroxybutyrate, or GHB) is an example of a compound that has
been shown to be highly efficacious in fibromyalgia.[101] It is a GABA precursor that improves the quality of
stages 3 and 4 of non-REM sleep. There is evidence to suggest that its use results in improvements in pain,
fatigue, and sleep in patients with fibromyalgia. However, in spite of the strong efficacy data, this drug has
not been widely approved for this use because of safety concerns. Nonetheless, the prominent simultaneous
salutary effects on pain, sleep, and fatigue strongly suggest that low GABA is an important therapeutic target
in fibromyalgia and related conditions. Sodium oxybate is used for the treatment of cataplexy in patients
with narcolepsy; however, it is a controlled drug and can only be obtained from one central pharmacy.[102]
Further research is being conducted in the US.[102]
Low-dose naltrexone
One published study has shown low-dose naltrexone to be effective in reducing symptoms of
fibromyalgia.[103] These findings have been confirmed in a separate, as yet unpublished, study.
Cannabinoids
Although cannabinoids are not widely approved for use in chronic pain, this class of drugs has displayed
efficacy in both fibromyalgia and other chronic pain conditions.[104] A systematic review of nabilone for
fibromyalgia found no convincing, high-quality evidence suggesting that it is of value in treating people with
fibromyalgia.[105]
Ketamine infusions
In addition to the serotoninergic and noradrenergic neurotransmitter systems, the glutaminergic system is
also clearly involved in fibromyalgia and more broadly in pain sensation, as evidenced by the fact that an
intravenous ketamine infusion seems to be predictive of subsequent responsiveness to dextromethorphan in
fibromyalgia but is not efficacious itself as long-term therapy.[106]
Memantine
One study has suggested that, in addition to blocking glutamatergic activity with either gabapentinoids or
ketamine, the drug memantine might be beneficial in treating fibromyalgia.[107]
Qi Gong
Qi Gong is a martial art therapy that is part of traditional Chinese medicine. Little evidence is available, but in
one study, patients demonstrated dramatic reductions in pain and improvements in functioning.[108]
Hydrotherapy
More commonly used in European countries, hydrotherapy, or the use of water for therapeutic purposes,
has been studied for fibromyalgia in small trials. Balneotherapy (bathing in warm or cold medicinal water or
mud) or spa therapy (bathing in mineral water) are forms of hydrotherapy. A meta-analysis found studies of
hydrotherapy in fibromyalgia to be of small size and poor quality, but suggested that hydrotherapy may result
in modest short-term reductions in pain for patients with fibromyalgia.[109]
Patient discussions
Before embarking on a treatment programme, it is very important to educate the patient about his or her
condition.[110] Emphasise that fibromyalgia can be managed but not cured, and that most patients can
function reasonably well if they play an active role in their therapy, which is likely to contain a combination
of drug and non-drug therapies.
Good resources include:[96]
• The Arthritis Foundation [Arthritis Foundation] (https://www.arthritis.org)

• Fibromyalgia Association UK [Fibromyalgia Association UK] (http://www.fibromyalgia-
MANAGEMENT
associationuk.org)
• University of Michigan FibroGuide. [University of Michigan FibroGuide] (https://
fibroguide.med.umich.edu)
Encouragement to exercise: patients should be counselled to aim for consistency first (exercising every
day of the week), then work on increasing duration of activity.
25
Advice on sleep hygiene: establishing consistent sleep times; avoiding daytime naps; getting consistent
exercise; paying attention to room environment; getting out of bed if not tired; using the bed only for
sleep or sex; not eating, drinking, or exercising just before bed; avoiding late-day caffeine and too much
alcohol.[111]
Advice on cognitive approaches: cognitive behavioural therapy (CBT) and biofeedback are specific
techniques that demonstrate effect sizes often greater than those for many of the pharmacological
treatments.
MANAGEMENT
Fibromyalgia Follow up
Prognosis
FOLLOW UP
Fibromyalgia is a chronic illness, and the patient can expect exacerbations and remissions to vary over time.
With good adherence to exercise, sleep, and behavioural therapy, most patients will improve over time.
The goal of treatment is to decrease physical and mental symptoms and to increase functioning, not to cure.
Treatment beyond behavioural therapy and exercise is often trial and error for individual patients.
27
Fibromyalgia Guidelines
Diagnostic guidelines
North America
ACTTION-APS Pain Taxonomy (AAPT) diagnostic criteria for fibromyalgia

(ht tps://www.jpain.org/article/S1526-5900(18)30832-0/fulltext)
Published by: ACTTION-APS Pain Taxonomy (AAPT) Last published: 2019
2016 revisions to the 2010/2011 fibromyalgia diagnostic criteria (ht tps://

www.sciencedirect.com/science/article/abs/pii/S0049017216302086)
Published by: Seminars in Arthritis and Rheumatism Last published: 2016
2012 Canadian guidelines for the diagnosis and management of fibromyalgia

syndrome (ht tps://rheum.ca/resources/publications)
Published by: Canadian Pain Society; Canadian Rheumatology Last published: 2012
GUIDELINES
Association
The American College of Rheumatology preliminary diagnostic

criteria for fibromyalgia and measurement of symptom severity (ht tps://
www.rheumatology.org/Practice-Quality/Clinical-Support/Criteria)
Published by: American College of Rheumatology Last published: 2010
Treatment guidelines
Europe
EULAR revised recommendations for the management of fibromyalgia

(ht tps://www.eular.org/recommendations_management.cfm)
Published by: European League Against Rheumatism Last published: 2017
Fibromyalgia Guidelines
North America
2012 Canadian guidelines for the diagnosis and management of fibromyalgia

syndrome (ht tps://rheum.ca/resources/publications)
Published by: Canadian Pain Society; Canadian Rheumatology Last published: 2012
Association
Ot tawa Panel evidence-based clinical practice guidelines for aerobic

fitness exercises in the management of fibromyalgia: part 1 (ht tps://
academic.oup.com/ptj/article/88/7/857/2742421)
Published by: Ottawa Panel Last published: 2008
Ot tawa Panel evidence-based clinical practice guidelines for

strengthening exercises in the management of fibromyalgia: part 2 (ht tps://
academic.oup.com/ptj/article/88/7/873/2742425)
Published by: Ottawa Panel Last published: 2008
GUIDELINES
Management of fibromyalgia syndrome (ht tps://jamanetwork.com/journals/
jama/fullarticle/199786)
Published by: American Pain Society Last published: 2004
29
Fibromyalgia Online resources
Online resources
1. Arthritis Foundation (https://www.arthritis.org) (external link)
2. Fibromyalgia Association UK (http://www.fibromyalgia-associationuk.org) (external link)
3. University of Michigan FibroGuide (https://fibroguide.med.umich.edu) (external link)

ONLINE RESOURCES
Fibromyalgia References
Key articles
• Rooks DS. Fibromyalgia treatment update. Curr Opin Rheumatol. 2007 Mar;19(2):111-7. Abstract
REFERENCES
(http://www.ncbi.nlm.nih.gov/pubmed/17278924?tool=bestpractice.bmj.com)
• Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004 Nov
17;292(19):2388-95. Full text (https://jamanetwork.com/journals/jama/fullarticle/199786) Abstract
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41
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43
Contributors:
// Authors:
Daniel J. Clauw, MD
Professor of Anesthesiology, Medicine, and Psychiatry
University of Michigan Health System, Ann Arbor, MI
DISCLOSURES: DJC has received consulting fees from Pfizer, Eli Lilly, Nuvo, Cerephex, Tonix, Abbott,
Forest Laboratories, Johnson & Johnson, Merck, Purdue Pharma, Zynerba, Astellas Pharmaceuticals,
Williams & Connolly LLP, and Aptinyx; he has received research grant support from Pfizer, Cypress
Biosciences, Forest Laboratories, Merck, Novo, Cerephex, and Aptinyx. DJC is an author of a number of
references cited in this topic.
// Acknowledgements:
Dr Daniel J. Clauw would like to gratefully acknowledge Dr Lisa Ware Corbin, a previous contributor to this
topic.
DISCLOSURES: LWC declares that she has no competing interests.
// Peer Reviewers:
Don Goldenberg, MD
Emeritus Professor of Medicine
Tufts University School of Medicine, Boston, MA
DISCLOSURES: DG declares that he has no competing interests.
Robert Bennet t, MD
Professor of Medicine and Nursing Research
Oregon Health & Science University, Portland, OR
DISCLOSURES: RB declares that he has no competing interests.

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Fibromyalgia

Straight to the point of care

Last updated: Apr 09, 2021

Stressors that may incite fibromyalgia include:

• Significant infection (e.g., Epstein-Barr virus [EBV] infection, Lyme disease)

History and exam

diffuse tenderness on examination (common)

Other diagnostic factors

sleep disturbance (common)

mood disturbance (common)

cognitive dysfunction (common)

numbness/tingling sensations (common)

sensitivity to sensory stimuli such as bright lights, odours, noises (common)

age between 20 and 60 years

Other tests to consider

Condition Differentiating signs / Differentiating tests

Vitamin D deficiency • Low vitamin D levels are • Serum 25-hydroxyvitamin D

Chronic fatigue syndrome • There is considerable • No differentiating tests.

Rheumatoid arthritis (RA) • As with other • RF or anti-cyclic citrullinated

Condition Differentiating signs / Differentiating tests

Osteoarthritis • Joint swelling and • X-rays are characteristic:

Ank ylosing spondylitis • Patients have limited • X-ray features are

Polymyalgia rheumatica • Patients are typically older • Erythrocyte sedimentation

but also with significant

Hypothyroidism • Patients with hypothyroidism • TSH is elevated and free T4

Condition Differentiating signs / Differentiating tests

ACR 2010 preliminary diagnostic criteria for fibromyalgia and

Fibromyalgia criteria and severity scales for clinical and

ACTTION-APS Pain Taxonomy (AAPT) diagnostic criteria for

2016 revisions to the 2010/2011 American College of Rheumatology

1. Generalised pain, defined as pain in at least 4 of 5 regions.

SSRI together with a tricyclic antidepressant can be helpful in fibromyalgia.[54]

Tricyclic antidepressants (TCAs)

Concomitant SNRI and TCA

Treatment algorithm overview

plus non-pharmacological therapies

adjunct interdisciplinary care

» amitriptyline: 10-70 mg orally once daily at

» cyclobenzaprine: 5-30 mg orally once daily

» duloxetine: 30-60 mg orally once daily;

» milnacipran: 12.5 mg orally once daily

» pregabalin: 75-225 mg orally twice daily,

» gabapentin: 300 mg orally once daily on

» amitriptyline: 10-70 mg orally once daily at

higher doses have been used, consult

» Drug classes with the most evidence

» All patients should probably be tried on one

» An SNRI is a good first choice for patients with

» A gabapentinoid may be a better first choice

» Caution should be used when prescribing

» It is very important to educate the patient

» While the treatment of depression and anxiety

» Derangement of the autonomic nervous

biofeedback training.[81] Electromyography

» naproxen: 500 mg orally initially, followed

» tramadol: 50 mg orally (immediate-release)

» Although non-steroidal anti-inflammatory

» However, in the setting of fibromyalgia with

» Referral to a psychologist is appropriate at

Vagus nerve stimulation (VNS)

Good resources include:[96]

• The Arthritis Foundation [Arthritis Foundation] (https://www.arthritis.org)

ACTTION-APS Pain Taxonomy (AAPT) diagnostic criteria for fibromyalgia

2016 revisions to the 2010/2011 fibromyalgia diagnostic criteria (ht tps://