The diagnosis of fibromyalgia (FM) is made clinically based on
the characteristic medical history and physical exam. For the condition to be
diagnosed, chronic symptoms must have been present for over three months.
Widespread pain and tenderness must be reported above and below the waist, as
well as along the axial spine bilaterally. Associated symptoms include fatigue,
sleep disturbances, and cognitive or mood disorders leading to impairment of
activities of daily living. Patients have a lifetime prevalence of depression
and anxiety of 74 percent and 60 percent, respectively.
The American College of Rheumatology published criteria for
diagnosing FM with a carefully taken history and a physical examination,
without the need for specialized training. The criteria include a Widespread Pain
Index and a Symptom Severity Index. The initial workup should include a CBC,
BMP, and UA, as well as a thyroid screen to rule out hypothyroidism. Low levels
of vitamin D, vitamin B-12, iron, or magnesium should be ruled out. Imaging
modalities are not necessary in the diagnosis of FM.
FM is best managed using a patient-centered, multidisciplinary
approach initiated in the primary care setting. Acknowledging the disease and
showing empathy to patients suffering from FM is important. Patients should
understand that FM is a chronic condition that requires long-term management.
Important nonpharmacologic therapies include education on
good sleep hygiene and a customized exercise plan. Patients should be
encouraged to gradually increase the amount of time that they exercise. Drug
monotherapy should be initiated if the nonpharmacologic approach is not
sufficient. Medications that have shown efficacy for chronic pain include antidepressants
and anticonvulsants. Tricyclic antidepressants are usually initiated first at a
low dose taken at bedtime and titrated up as tolerated. They are effective at
reducing pain, fatigue and sleep disturbances. Most FM patients are started on amitriptyline,
but desipramine has fewer anticholinergic side effects and less cardiotoxicity.
For patients with moderate symptoms, cyclobenzaprine may be an acceptable
alternative, but it has minimal antidepressant effect. Patients who do not
respond to tricyclics or who have depression may benefit from selective serotonin
and norepinephrine reuptake inhibitors. Duloxetine and milnacipran are approved
Anticonvulsants that have shown benefits for
chronic pain include gabapentin and pregabalin; they are also preferred in
patients with severe sleep problems. Nonsteroidal anti-inflammatory drugs and acetaminophen
have not been shown to be very effective for FM chronic pain but can be used to
manage acute flareups or nociceptive pain from comorbidities such as
arthritis. Tramadol is the only analgesic that has been shown to effectively
improve FM chronic pain.
If symptoms persist with a single pharmacotherapy at the
highest dose tolerated by the patient, a combination of drugs should be
considered. Patients should also be referred to a rheumatologist or to other specialists
to manage a complex drug regimen or comorbidities. Depression should be treated
aggressively, and patients should see a psychiatrist or may benefit from
psychological intervention, including cognitive behavioral therapy. Additional
treatments that can be considered include trigger point injections, acupuncture,
physical therapy, and chiropractic treatment.