eMedicine Specialties > Pediatrics: General Medicine > Rheumatology
Fibromyalgia: Treatment & Medication
Updated: Dec 10, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Effective treatment of fibromyalgia syndrome (FMS) requires a multidisciplinary approach because of the multifaceted problems that develop. The goals of treatment are to reduce pain and depression, to decrease sleep disturbances, and to promote physical activity. In addition, a number of cognitive-behavioral interventions may help to improve the disorder. Activity is a mainstay in the treatment of fibromyalgia syndrome (see Activity).
- Support: Although a better understanding of what causes fibromyalgia syndrome would be helpful in determining treatment options, a holistic approach to the child and family living with this problem is the current recommendation. Supporting the child and family to maintain as normal a lifestyle as possible is important because they live with a potentially chronic disorder. Emphasis on both the child's and the family's understanding of the disorder is helpful in learning to live with and overcome the problems. Attendance at school and other usual activities is imperative. Modifying participation or attendance may be necessary in light of the child's ability to keep up with the expected activities.
- Sleep: Bennett and Tayag-Kier et al suggested that a sleep analysis in children is helpful in determining treatable causes of sleep disturbance and periodic limb movement in sleep (PLMS).2,12 Few studies have involved children; however, low-dose tricyclic antidepressants or cyclobenzaprine has been used to help promote deeper sleep. Gedalia et al first tried cyclobenzaprine at bedtime to help promote sleep and then switched to low-dose antidepressants when 25% of the patients did not respond to the muscle relaxant.11
- Psychologic treatment
- The use of cognitive-behavioral therapy has proven helpful in some cases. Conte et al compared children with juvenile primary fibromyalgia syndrome with healthy children and those living with arthritis.13 Findings showed that children and adolescents with juvenile primary fibromyalgia syndrome showed increased levels of anxiety and depression, greater temperamental instability, higher pain sensitivity, and less family cohesion than healthy children or those with arthritis.
- Degotardi et al studied 67 children with juvenile primary fibromyalgia syndrome (JPFS) using an educational and behavioral approach that addressed sleep difficulties, pain management, and exercise. They found significant differences in all physicals between preintervention and postintervention.16
- Walco and Ilowite found that the use of a cognitive-behavioral program showed improvement in symptoms over a 4-month to 24-month period.17 Likewise, Vereker studied the use of counseling, behavioral techniques, and physical activity in 5 children who had shown improvement in symptoms.
- Kashikar-Zuck et al found that children with JPFS had higher levels of depression than children with nonmalignant back pain, possibly because of the longer time taken for those with JPFS to receive specialty care and treatment for the problem.18
- Pharmacologic pain control: See Medication.
- Cognitive-behavioral approaches including activity and exercise: The literature supports the therapeutic use of exercise and activity as an important treatment aspect of JPFS. A meta-analysis by Rossy et al found better outcomes with the use of cognitive-behavioral interventions and exercise than with medication.19 Degotardi et al studied JPFS using exercise and a cognitive-behavioral approach and also found that cognitive-behavioral therapy strategies helped children effectively manage musculoskeletal pain associated with the disorder.16
Surgical Care
No surgical treatment is indicated.
Consultations
Because of the multifaceted symptoms that present, refer the patient to other subspecialists for evaluation and treatment.
- Physical medicine and rehabilitation specialist
- Rheumatologist
- Psychiatrist/psychologist
- Pulmonary medicine specialist for evaluation of sleep disorders that may cause fatigue and the presence of PLMS
- Orthopedist
Activity
- An essential component of the treatment regimen, routine exercise consists of moderate exercise, such as brisk walking for 20 minutes 3 times per week and progression as tolerated. In 2000, Gedalia et al recommended physical therapy guidance to low-impact exercises, such as stretching, walking, biking, and swimming, at least half an hour per day, to improve cardiovascular fitness.11
- The goal of an exercise regime is to improve cardiovascular health and musculoskeletal fitness through nonimpact aerobic activity.
- Returning to normal activity is imperative for the child who has stopped sport and social activities because of pain; this helps to modulate the pain. A physical therapist may be extremely helpful in establishing a reasonable exercise and activity regime.
- Other modalities found to be helpful in modulating pain include hypnotherapy, cognitive-behavioral intervention, physical therapy, and transcutaneous electrical nerve stimulation (TENS). Using palliative measures to treat symptoms and minimizing physical disability is an important treatment mainstay.
- Maintaining the child's physical conditioning is imperative in the long-term outcome of fibromyalgia syndrome.
Medication
The medication treatment for juvenile primary fibromyalgia syndrome (JPFS) is inferred for what has been studied and used in adult fibromyalgia. Typical medication regimens for pediatric fibromyalgia syndrome (FMS) primarily include skeletal muscle relaxants and low-dose tricyclic antidepressants. Some evidence reports that pain and symptom management with nonsteroidal anti-inflammatory drugs (NSAIDs) in combination with antidepressants and nonaddictive analgesics is effective. The most well-described medications used in the treatment of pediatric fibromyalgias include NSAIDs, low-dose tricyclic antidepressants, skeletal muscle relaxants, and selective serotonin reuptake inhibitors (SSRIs).
Low-dose antidepressants, such as amitriptyline (Elavil), and skeletal muscle relaxants, such as cyclobenzaprine (Flexeril), help decrease the hyperarousal mechanisms in fibromyalgia and, in turn, help the child and adolescent sleep better. Both medications are administered at bedtime or 1-2 hours before bedtime. Some debate surrounds which medication should be initially used. Some suggest the use of cyclobenzaprine first in treatment, whereas others suggest beginning medication therapy with low-dose tricyclic antidepressants.11 An adult study found the combination of a low dose tricyclic antidepressants (amitriptyline) and fluoxetine (an SSRI) effective in improving, sleep quality, pain, and fatigue.20 A current level 3 clinical trial of fluoxetine (Prozac) to test its efficacy in treating JPFS is underway.
Depending on which medication is started first, either skeletal muscle relaxants or low-dose tricyclic antidepressants have been used when the child or adolescent does not respond to the initial medication. An NSAID or acetaminophen is used in conjunction with the muscle relaxants or antidepressants in some cases that are unresponsive to the mainstay therapies alone. Active investigation is underway to look at the potential role for S-adenosylmethionine (SAMe) and the selective serotonin reuptake inhibitors (SSRIs) in the adult population.
Antidepressants
These agents help decrease pain intensity and improve sleep quality. They counteract the hyperarousal mechanism in fibromyalgia syndrome and promote deeper sleep in children and adolescents. Both medications are administered at bedtime or 1-2 hours before bedtime. SSRIs have been found useful for treating chronic pain states in adults.
Amitriptyline (Elavil)
Used for analgesia for certain chronic and neuropathic pain conditions.
Adult
30-100 mg PO qhs
Pediatric
<2 years: Not recommended
Children: 0.1 mg/kg PO qhs, may increase as tolerated over 2-3 wk to 0.5-2 mg/kg PO qhs
Adolescents: 5-40 mg PO qhs or 2 h before bedtime
Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Documented hypersensitivity; MAOI use in past 14 d; seizures; cardiac arrhythmias; glaucoma; urinary retention
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiac conduction disturbances and history of hyperthyroidism and renal or hepatic impairment
Skeletal muscle relaxants
These agents may act centrally by a selective action on the CNS and are principally used for relieving painful muscle spasms or spasticity that occurs in musculoskeletal and neuromuscular disorders. Their mechanism of action may be due, in part, to their CNS-depressant activity.
Cyclobenzaprine (Flexeril)
Helps decrease the hyperarousal mechanisms in FMS and, in turn, helps the child sleep better. Is structurally related to tricyclic antidepressants and exhibits similar pharmacologic effects. Primarily acts on the CNS at the brain stem level.
Adult
20-40 mg/d PO divided bid/qid; not to exceed 60 mg/d
Pediatric
<15 years: Not established
>15 years: 5-30 mg PO qhs
Coadministration with MAOIs and tricyclic antidepressants may increase toxicity; cyclobenzaprine may have additive effect when used concurrently with anticholinergics; effects of alcohol, CNS depressants, and barbiturates may be enhanced with cyclobenzaprine
Documented hypersensitivity; concomitant use of MAOIs; MAOI use in last 14 d; depression; hyperthyroidism; urinary retention; cerebral palsy; QT prolongation
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in urinary retention, angle-closure glaucoma, or increased intraocular pressure; may cause drowsiness, dizziness, and xerostomia
Nonsteroidal anti-inflammatory drugs and miscellaneous analgesics
These agents are used for their anti-inflammatory, analgesic, and antipyretic effects. They are useful for the relief of mild-to-moderate pain.
Ibuprofen (Advil, Motrin)
May help achieve analgesia when used in combination with skeletal muscle relaxants or tricyclic antidepressants. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
4-10 mg/kg/dose PO q6-8h; not to exceed 2.4 g/d
Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Acetaminophen (Tylenol, Feverall, Tempra)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, patients with upper GI disease, or those who are taking PO anticoagulants.
Adult
325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h
Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-P deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible with overdose or long-term high doses; severe or recurrent pain or high or continued fever may indicate a serious illness; contained in many OTC products and combined use with these products may result in cumulative doses exceeding recommended maximum dose
More on Fibromyalgia |
| Overview: Fibromyalgia |
| Differential Diagnoses & Workup: Fibromyalgia |
 Treatment & Medication: Fibromyalgia |
| Follow-up: Fibromyalgia |
| Multimedia: Fibromyalgia |
| References |
| « Previous Page | Next Page » |
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Further Reading
Keywords
fibromyalgia, fibrositis, myofascial syndrome, nonarticular rheumatism, soft tissue rheumatism, fibromyalgia syndrome, FMS, juvenile primary fibromyalgia syndrome, juvenile FMS, pediatric fibromyalgia syndrome, pediatric FMS, juvenile primary FMS, juvenile primary fibromyalgia syndrome, JPFS, anxiety, stress, weather changes, irritable bowel symptoms, poor memory, tension headaches, dizziness, fluid retention, paraesthesias, restless legs, bruising, Raynaud phenomenon, sleep disturbance, central sensitivity syndromes, CSS, juvenile chronic arthritis, periodic limb movement in sleep, PLMS, migraines, restless leg syndrome, joint edema, temporomandibular disorders, myofascial pain syndrome, female urethral syndrome, interstitial cystitis, multiple chemical sensitivity syndrome, posttraumatic stress disorder
