Practice Essentials
Fibromyalgia is a disorder of chronic, widespread pain and tenderness (see the image below). It typically presents in young or middle-aged women but can affect patients of either sex and at any age.
Tender points in fibromyalgia.
See Fibromyalgia: Slideshow, a Critical Images slideshow, for more information on strategies for accurately diagnosing and treating fibromyalgia.
Signs and symptoms
Fibromyalgia is a syndrome that consists of the following signs and symptoms
:
Persistent (≥3 mo) widespread pain (pain/tenderness on both sides of the body, above and below the waist, including the axial spine [usually the paraspinus, scapular, and trapezius muscles])
Stiffness
Fatigue; disrupted and unrefreshing sleep
Cognitive difficulties
Multiple other unexplained symptoms, anxiety and/or depression, and functional impairment of activities of daily living (ADLs)
See Presentation for more detail.
Diagnosis
Fibromyalgia is a diagnosis of exclusion and patients must be thoroughly evaluated for the presence of other disorders that could be the cause of symptoms before a diagnosis of fibromyalgia is made. The clinical assessment may reveal objective evidence for a discrete or comorbid illness, such as the following:
Hypothyroidism
Rheumatoid arthritis
Systemic lupus erythematosus
Polymyalgia rheumatic
Other inflammatory or autoimmune disorders
Serious cardiac conditions in those with chest pain, dyspnea, and palpitations
Laboratory testing
Although patients with fibromyalgia do not have characteristic or consistent abnormalities on laboratory testing, routine laboratory and imaging studies can help to rule out diseases with similar manifestations and to assist in diagnosis of certain inflammatory diseases that frequently coexist with fibromyalgia. Such tests include the following:
Complete blood count with differential
Metabolic panel
Urinalysis
Thyroid-stimulating hormone level
25-hydroxy vitamin D level
Vitamin B12 level
Iron studies, including iron level, total iron binding capacity, percent saturation, and serum ferritin level
Magnesium level
Erythrocyte sedimentation rate
Antipolymer antibody assay: May provide conclusive evidence for a subgroup of people with fibromyalgia; about 50% of fibromyalgia patients have antipolymer antibodies
Patient self-report forms, clinical psychometric testing
Self-report forms, for assessing patients’ pain, fatigue, and overall status, include the following:
Modified Health Assessment Questionnaire
Fibromyalgia Impact Questionnaire
Checklist of current symptoms
Scales for helplessness and cognitive performance
The Physician Health Questionnaire–9 for depression
The Generalized Anxiety Disorder–7 questionnaire for anxiety
The Mood Disorder Questionnaire to screen for bipolar disease
Psychometric testing provides a more comprehensive assessment and includes the following:
Minnesota Multiphasic Personality Inventory
Social Support Questionnaire
Sickness Impact Profile
Multidimensional Pain Inventory
See Workup for more detail.
Management
There is no cure for fibromyalgia, but education, lifestyle changes, and proper medications can help the individual to regain control and achieve significant improvement.
Models of pain behavior that interrelate biologic, cognitive, emotional, and behavioral variables form the basis for cognitive-behavioral and operant-behavioral approaches to adult pain management. Fibromyalgia in children responds to a combination of psychotherapy, exercise, relaxation techniques, and education. Pharmacotherapy is generally not indicated in children.
Nonpharmacotherapy
Diet (eg, promote good nutrition, vitamin supplementation, bone health, weight loss)
Stress management
Aerobic exercise (eg, low-impact aerobics, walking, water aerobics, stationary bicycle)
Sleep therapy (eg, education/instruction on sleep hygiene)
Psychologic/behavioral therapy (eg, cognitive-behavioral, operant-behavioral)
Pharmacotherapy
Always combine pharmacologic and nonpharmacologic therapy in the treatment of fibromyalgia. Aggressively treat comorbid depression.
Medications used in the management of fibromyalgia include the following:
Analgesics (eg, tramadol)
Antianxiety/hypnotic agents (eg, alprazolam, clonazepam, zolpidem, zaleplon, trazodone, buspirone, temazepam, sodium oxybate)
Skeletal muscle relaxants (eg, cyclobenzaprine)
Antidepressants (eg, amitriptyline, duloxetine, milnacipran, venlafaxine, desvenlafaxine)
Anticonvulsants (eg, pregabalin, gabapentin, tiagabine)
Alpha 2 agonists (eg, clonidine)
Medications that may prove helpful for sleep problems that do not respond to nonpharmacotherapy include the following:
Antidepressants (eg, trazodone, SSRIs, SNRIs, tricyclic antidepressants)
Anticonvulsants (eg, clonazepam, gabapentin, tiagabine)
Nonbenzodiazepine hypnotics (eg, zolpidem, zaleplon, eszopiclone)
Muscle relaxants (eg, cyclobenzaprine, tizanidine)
Dopamine agonists (eg, pramipexole)
Other agents used in fibromyalgia may include the following:
Vitamins and minerals
Malic acid and magnesium combination
Antioxidants
Amino acids
Herbs and supplements
See Treatment and Medication for more detail.