Monday, May 29, 2023


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.

Tender points in fibromyalgia.

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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])


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.


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:


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


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.


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.


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)


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


Amino acids

Herbs and supplements

See Treatment and Medication for more detail.

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