Sections

Fibromyalgia

Treatment

Approach Considerations

The physician should inform the patient that no cure exists for fibromyalgia but that education, lifestyle changes including regular physical activity, and proper medications can help the individual to regain control and achieve significant improvement.^[103]When patients with fibromyalgia fully understand the nature of the disease, they are more likely to comply with treatment and to take an active role in managing the disease.

European League Against Rheumatism (EULAR) 2016 guidelines recommend that initial management of fibromyalgia involve patient education and focus on nonpharmacological therapies. Patients whose condition fails to respond should receive treatment tailored to their specific needs, such as psychological therapies for mood disorders and unhelpful coping strategies, pharmacotherapy for severe pain or sleep disturbance, and/or a multimodal rehabilitation program for severe disability. EULAR noted that most treatments have only a relatively modest effect.^[104]

At the initial visit, give patients educational materials about fibromyalgia, including a list of resources, such as Web sites, books, videotapes, newsletters, and brochures, related to the disease. Some authors recommend encouraging patients to attend their local fibromyalgia support group. Provide education and support to the patient's significant family members.

Therapeutic recommendations for fibromyalgia can now be based almost entirely on evidence from well-designed randomized controlled trials. Models of pain behavior that interrelate biologic, cognitive, emotional, and behavioral variables form the basis for cognitive-behavioral and operant-behavioral approaches to pain management. Wood published a useful summary of therapeutic approaches to central sensitivity syndrome (CSS) comorbidities in fibromyalgia.^[105]

The first crucial element in the treatment of pain, fatigue, and other diverse symptoms in patients with fibromyalgia is for the clinician to validate the patient’s illness through empathetic listening and acknowledgment that the patient is indeed experiencing pain.^{[27, 34, 106, 107, 108, 109, 110, 111, 112]}Comments such as "it’s all in your mind" or "I cannot find anything wrong with you" only add to the patient's frustration.

Avoid excessive use of physical therapy modalities after minor trauma, excessive activity limitation, and overly liberal work release. Be aware of confounders to recovery, such as pending litigation or compensation claims.

The overall approach for chronic pain in fibromyalgia involves a multifaceted treatment plan that incorporates various adjuvant medicines, aerobic and resistance exercise, and psychological and behavioral approaches to reduce distress and promote self-efficacy and self-management (eg, relaxation training, activity pacing, visual imagery, distraction).

If significant nociceptive pain coexists with the diffuse chronic pain of fibromyalgia, manage it pharmacologically with non-narcotic medications such as antidepressants, anticonvulsants, or muscle relaxers. For associated regional chronic pain syndromes (eg, temporomandibular disorder), referral to an experienced specialist who advocates nonsurgical approaches is recommended.

In a systematic review by Häuser of 1119 patients in 9 randomized controlled trials, multicomponent treatment (at least 1 form of educational or other psychological therapy plus at least 1 form of exercise therapy) yielded short-term benefits for the symptoms of pain, fatigue, depression, and quality of life. They found no evidence that these symptomatic benefits were durable in the long term, but strong evidence suggested that multicomponent therapy conferred a long-term benefit to maintenance of physical fitness.^[113]

Poor sleep is virtually universal in fibromyalgia and contributes importantly to pain, depression, and fatigue. Accurate diagnosis and pharmacologic and nonpharmacologic management are essential.^{[114, 115, 116]}

Trigger point injections, acupuncture, chiropractic manipulation, and myofascial release are usually well received by patients and can be beneficial, but results are not long lasting. In addition, patients may not be able to afford long-term therapy since these are sometimes not covered by insurance.

A possible etiologic link between Chiari malformation and fibromyalgia has been suggested. However, no generally accepted evidence indicates that skull surgery for correction of Chiari malformation is of benefit in patients with fibromyalgia, and screening all fibromyalgia patients for Chiari formation is not recommended.

Treatment of Children and Adolescents

Fibromyalgia in children responds to a combination of psychotherapy, exercise, relaxation techniques, and education. Pharmacotherapy is generally not indicated or recommended. Stephens et al conducted a 12-week randomized controlled trial of exercise intervention in children with fibromyalgia and found that both aerobics and qigong yielded benefits in terms of fibromyalgia symptoms, pain, and quality of life in this population. Aerobics were found to be advantageous in several measures.^[117]

Juvenile-onset fibromyalgia in adolescents is unlikely to resolve spontaneously. A prospective longitudinal study found that more than 80% of adolescents with juvenile-onset fibromyalgia continued to have symptoms into adulthood. At a mean age of 21 years, approximately half met American College of Rheumatology criteria for adult fibromyalgia.^{[118, 119]}

Duloxetine (Cymbalta) was approved by the US Food and Drug Administration (FDA) in April 2020 for fibromyalgia in adolescents aged 13-17 years. In a randomized, placebo-controlled trial, a total of 184 patients with juvenile fibromyalgia received duloxetine (n = 91) or placebo (n = 93), of which 149 patients (81%) completed the 13-week double-blind treatment period. Of those, significantly more patients on duloxetine compared with placebo had at least a 30% or 50% reduction in pain severity.^[120]

For more information, see Juvenile Primary Fibromyalgia Syndrome.

Managing Flare-ups

Patients should learn to identify the factors that trigger flare-ups (although, on occasion, no trigger can be identified) and what measures to take to decrease their symptoms.^[111]Tips for avoiding and managing flare-ups include the following:

Treat infections quickly
Avoid changes in diet
Exercise as prescribed (ask patients not to increase their routine without consulting a physician)
Moderate changes in activity
Avoid unnecessary life changes
Treat changes in mood or sleep early and aggressively
Always start new medications at the lowest possible dose
Prepare for unavoidable situations that have caused flare-ups in the past (eg, arrange for an increase in sleep medication or for help with housework and child care)
Encourage patients to pace their activities and know their limits

Psychological and Behavioral Therapy

Depression, anxiety, stress, sleep disturbance, pain beliefs and coping strategies, and self-efficacy all are central to the pain experience in many patients and frequently determine the outcome of chronic pain. Depression must be treated aggressively.

Unless psychosocial and behavioral variables are recognized and approached, strictly pharmacologic interventions are of limited benefit. Cognitive-behavioral therapy (CBT) and operant-behavioral therapy (OBT) both effect clinically meaningful improvements in pain intensity and physical impairment in approximately one third to one half of patients with fibromyalgia.^[121]

Pretreatment patient characteristics are important predictors of response to nonpharmacologic therapies.^[122]High levels of affective distress, poor coping skills, few pain behaviors, and unsolicitous spouse behavior predict response to CBT. Prominent pain behaviors, high levels of physical impairment, catastrophizing, and solicitous spouse behavior predict response to OBT.

Other useful strategies include the following:

Relaxation training
Activity pacing
Guided imagery
Written emotional disclosure
Distraction strategies
Instruction in proper sleep hygiene

Depression in fibromyalgia may be treated with a regimen that includes nonpharmaceutical therapies. Treating depression alone does not cure fibromyalgia. Antidepressants may help, but the clinician also should address other symptoms, such as fatigue or pain. Modifying diet and practicing good sleep hygiene are crucial. Starting a rehabilitation exercise program is important. Behavioral modification techniques and stress management may also be used.

A meta-analysis by Häuser et al of randomized controlled clinical trials found strong evidence that antidepressants reduced pain, fatigue, depressed mood, and sleep disturbances and improved health-related quality of life in patients with fibromyalgia.^[123]The study included analysis of tricyclic and tetracyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), serotonin and noradrenaline reuptake inhibitors (SNRIs), and monoamine oxidase inhibitors in 1427 participants.

In a study of patients with fibromyalgia who were taking an SSRI or an SNRI for comorbid depression, Arnold et al reported that the addition of pregabalin significantly improved pain, anxiety, and depression and improved sleep quality, compared with placebo.^[124]

Physical Therapy/Physical Modalities

Because many patients with chronic pain fear that activity will worsen their pain and fatigue, they become deconditioned. In fact, limitations on activity, including work release, should generally be avoided. Graded aerobic exercise (eg, low-impact aerobics, walking, water aerobics, stationary bicycle) is an integral part of optimum treatment in patients with fibromyalgia.

However, exercise programs should start gently and progress gradually to endurance and strength training. Patients should avoid prolonged, overly strenuous physical exercise before reconditioning is established.

The benefits of exercise for patients with fibromyalgia include improvement in subjective and objective measures of pain and in an overall sense of well-being.^{[112, 125, 126]}

In a randomized controlled trial, Munguía-Izquierdo and Legaz-Arrese found that unfit women with severe fibromyalgia symptoms benefitted from aquatic therapy (in a warm pool) 3 times per week for 16 weeks. This approach also resulted in greatly improved adherence to exercise in the study participants.^[127]

Qigong, a traditional Chinese practice that is currently characterized as meditative movement, has demonstrated benefit in fibromyalgia. However, the best outcomes require diligent practice. Four trials in 201 subjects who practiced qigong for 30-45 minutes daily over 6-8 weeks found significant and consistent benefits in pain, sleep, impact, and physical and mental function, with benefits maintained at 4-6 months.^[128]

Tai chi resulted in greater improvement in fibromyalgia symptom scores than did aerobic exercise, in a randomized controlled trial by Wang et al in 226 patients. Patients randomized to tai chi were enrolled in one of four regimens: supervised sessions once or twice weekly for 12 or 24 weeks. Aerobic exercise comprised supervised sessions twice weekly for 24 weeks. Participants were also advised to perform tai chi or aerobic exercise on their own for 30 minutes daily.^[129]

At 24 weeks, the change in fibromyalgia severity score was significantly greater in the four tai chi groups combined than in the aerobic exercise group, but the difference was not clinically meaningful. However, tai chi twice weekly for 24 weeks provided substantial clinical benefit compared with aerobic exercise.^[129]

Heat, massage, and other treatments are useful. Diffuse and regional pain is improved by strategies such as saunas, hot baths and showers, hot mud, and massage. However, excessive dependence on administration of physical therapy and modalities by another person may confound the patient's efforts to achieve self-efficacy for pain control.

Encouragement and positive reinforcement can improve compliance. Obesity, poor posture, and overloading activities at work and at home should be addressed.

Pharmacologic Therapy

The treatment of fibromyalgia (FM) should always combine pharmacologic approaches with nonpharmacologic therapy, especially stress management, aerobic exercise, and, in some cases, psychological counseling. Aggressively treat comorbid depression and anxiety.

Patients with fibromyalgia have difficulty tolerating regular doses of most medications and supplements. They are sensitive to medications, and often experience adverse effects. To avoid those problems, use the lowest dose available or perhaps one half to one quarter of the lowest recommended dose.

Many fibromyalgia patients have cognitive dysfunction that limits their ability to understand and process verbal information. Avoid complications and confusion by providing easily understandable written instructions on medication use. Patients should be instructed to consult their physician before starting any over-the-counter (OTC) medications or supplements to avoid potentially harmful drug interactions.

The US Food and Drug Administration (FDA) has approved three drugs for use in fibromyalgia: pregabalin (Lyrica), duloxetine (Cymbalta), and milnacipran (Savella).^[130] Pregabalin is used to reduce pain and improve sleep. The antidepressants duloxetine and milnacipran, which are used to relieve pain, fatigue, and sleep problems, are generally prescribed at lower doses than for treatment of depression.

In randomized, controlled trials, a significantly higher proportion of patients have experienced > 30% improvement from baseline in pain with pregabalin, duloxetine, or milnacipran, compared with placebo. However, a meta-analysis found no significant difference in the efficacy and tolerability of the three drugs, when given at the recommended doses.^[131]

Other anticonvulsants and antidepressants are often used off-label to treat fibromyalgia and there is evidence that many can decrease pain sensitivity. In particular, tricyclic antidepressants (TCAs) have proven benefit but anticholinergic side effects often limit their use. Corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs) are useful only for management of coexisting inflammatory processes and are not recommended as first-line therapies. Pharmacologic and nonpharmacologic treatment of poor sleep is crucial for improving the patient's overall sense of well-being.

Anecdotally, dextromethorphan, an N-methyl-D-aspartate (NMDA) receptor antagonist available as an over-the-counter (OTC) antitussive, and naltrexone, an opioid receptor antagonist, have been used to treat fibromyalgia, but placebo-controlled trial data is lacking. Topical capsaicin, obtained from red chili peppers, is essentially free of toxicity, other than mild burning at the site of application, and can be a useful adjunct in combination with gentle massage.

Beta-blockers and/or increased fluid and sodium/potassium intake may benefit a subset of patients with fibromyalgia who have orthostatic hypotension, palpitation, and vasomotor instability. Growth hormone and cytokine therapies are still experimental.^[132]

Several medications should be avoided or used carefully. Opioids, hypnotics, anxiolytics, and certain skeletal-muscle relaxants must be used with caution because of the potential for abuse and the risk of worsening fatigue and cognitive dysfunction.

Analgesics

NSAIDs and acetaminophen are of limited efficacy in reducing pain due to fibromyalgia but are important adjuncts for nociceptive pain generators, such as osteoarthritis and degenerative spondylosis.^[133] Topical anesthesia with lidocaine (5% Lidoderm patch) can also be helpful in this regard.

Tramadol, a weak opioid agonist with additional effects on serotonin and norepinephrine receptors, improves pain associated with fibromyalgia. A trial of tramadol may be considered for second-line therapy in patients with moderate to severe pain that is unresponsive to other treatments. ^[103] ^[134] In a 12-month observational study of opioid use in 1700 adult patients with fibromyalgia, tramadol proved superior to other opioids for improving pain-related interference with daily living, functioning, depression, and insomnia. ^[135]

Opioid analgesics with more potency (eg, hydrocodone, oxycodone, fentanyl, morphine), although frequently prescribed in patients with fibromyalgia, appear to be of limited efficacy in most patients with this disorder and are generally not recommended. However, in addition to utility in the treatment of severe nociceptive pain (eg, radicular pain, advanced osteoarthritis of the knee), opioid analgesics may reduce pain, improve quality of life, and occasionally restore function in a patient with fibromyalgia who has severe allodynia and who has not responded to other approaches.

More often, rheumatologists discover that patients with fibromyalgia are already taking very high doses of opioids prescribed by their family physician. The task is then to gradually withdraw opioids, if possible, or perhaps switch therapy to reasonable doses of methadone (eg, 5-10 mg tid). Tapering takes 2-3 weeks; clonidine, 0.2-0.4 mg/day, is helpful for controlling withdrawal symptoms. Remember that opioid-induced hyperalgesia can be a paradoxical complication of high-dose opioid therapy.

Monitoring of patients receiving opioid medications requires frequent reevaluation for efficacy, improvement in daily functioning, and adverse effects during initiation, titration, and maintenance therapy, especially in older patients. The patient should sign a "narcotics contract" that specifies the following:

One prescribing physician
One dispensing pharmacy
Acceptance of no new prescription of opioids if the medication runs out early or is lost or stolen
Agreement for random urine testing

Antianxiety agents

Agents of varying durations of action are used frequently for anxiety and panic and as sleep aids (poor sleep is nearly universal in fibromyalgia).^[116] Antianxiety agents are often used in combination with antidepressants and anticonvulsant drugs (both of which also have efficacy for anxiety and insomnia) and include benzodiazepines (eg, alprazolam [Xanax, Niravam; half-life, < 12 h], temazepam [Restoril; half-life, 10-15 h], clonazepam [Klonopin; half-life, 25-100 h], buspirone, trazodone [Oleptro]).

In considering the choice of an anxiolytic drug, remember that many antidepressants also have indications for anxiety. The short-acting nonbenzodiazepine hypnotics zolpidem (Ambien) and zaleplon (Sonata), along with careful attention to optimum sleep hygiene, are useful in the treatment of insomnia but have no effect on pain in fibromyalgia.

An effective combination is zolpidem at bedtime as needed, plus zaleplon (5 mg)—which has a very short half-life—for awakenings in the middle of the night. Patients who do not experience improved sleep with the above and with careful attention to good sleep hygiene should be referred for polysomnography.

Sodium oxybate (Xyrem),^[136] a sedative hypnotic, prolongs stage III/IV restorative sleep, which is essential to feeling rested and refreshed on awakening. Such deep sleep is usually disrupted in patients with fibromyalgia, leaving the patient stiff, sore, and exhausted upon awakening.

Sodium oxybate is currently approved by the FDA for narcolepsy-associated cataplexy and excessive daytime sleepiness. In phase III trials, it has proved effective for relief of pain and fatigue and for sleep quality and patient global improvement.^[137] Because of its potential for abuse, dependence, and diversion (date rape), it is available only through a centralized pharmacy (1-866-997-3688).

Antidepressants

Low-dose TCAs have proved to have short-term efficacy for pain control, improved sleep, and improved sense of well-being in patients with fibromyalgia. However, adverse anticholinergic effects (eg, dry mouth, drowsiness, weight gain) often limit patient acceptance/tolerance.

First-generation selective serotonin reuptake inhibitors (SSRIs), including fluoxetine (Prozac) and paroxetine (Paxil, Pexeva), improve symptoms in fibromyalgia but the high doses required often cause adverse effects that are poorly tolerated. For this reason, the SSRIs have largely been replaced as a treatment for fibromyalgia by dual serotonin/norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine (Effexor), desvenlafaxine (Pristiq), levomilnacipran (Fetzima), milnacipran (Savella),^[138]or duloxetine (Cymbalta).^{[139, 140, 141]}

Milnacipran has been approved for use in fibromyalgia by the FDA. Duloxetine has been shown to improve pain in fibromyalgia irrespective of comorbid depression^[142]and is currently approved by the FDA for pain in fibromyalgia. SNRIs can cause nausea, so they should be taken with food.

A useful combination is a TCA (eg, amitriptyline, nortriptyline) in low dosage at bedtime plus a first-generation SSRI (eg, fluoxetine, paroxetine), which allows for improved efficacy with lower dosing that can help prevent adverse effects.^[143]However, patients taking combinations of serotonin-active drugs should be closely monitored for the development of serotonin syndrome,^[144]and all patients taking antidepressants should be carefully monitored for worsening depression or the emergence of suicidal thoughts.

While many patients find relief with the above-mentioned antidepressants, some fail to tolerate them. For those patients, antidepressants that work via alternative mechanisms are reasonable options. Animal studies have shown that 5-HT1A receptor activation can induce analgesia.^{[145, 146]}

Currently available drugs with 5-HT1a receptor agonist activity include buspirone (Buspar), vilazodone (Viibryd), and vortioxetine (Brintellix). Buspirone is indicated as an anti-anxiety agent and is also used off-label to augment antidepressant activity, while vilazodone and vortioxetine are both indicated only for the treatment of depression. The most common side effect of both vilazodone and vortioxetine is nausea, so both should be taken with food. All three medications should be started in the morning, since they can cause activation.

Bupropion is structurally different from other antidepressants and its ability to reduce pain is due to its inhibition of the neuronal reuptake of norepinephrine and dopamine.^{[145, 146]}While bupropion is available in an extended release (ER) preparation that allows for once daily dosing, it is activating and can cause or worsen insomnia, so patients should start with immediate-release tablets in the morning with gradual up-titration, or switch to the ER preparation as tolerated. The activating aspect of bupropion can be particularly helpful for fatigue, which is common in fibromyalgia.

Anticonvulsants

Anticonvulsants are useful for chronic pain states, including fibromyalgia and related syndromes and various types of neuropathic pain, and serve as adjunctive medications for disturbed sleep and anxiety. While multiple choices are available, the most studied options for fibromyalgia are gabapentin^[147]and pregabalin (Lyrica).^{[148, 149, 124]} Other options include the following:

Tiagabine
Levetiracetam
Topiramate
Zonisamide
Oxcarbazepine

Anticonvulsants often cause sedation, so they should be started using low doses at night with gradual up-titration and/or use during the day. One option for improving tolerability and efficacy of anticonvulsants is by combining them with antidepressants. Studies have shown benefits from combining pregabalin with milnacipran^[150] as well as gabapentin with venlafaxine,^[151] and the author's personal experience has shown that other combinations of anticonvulsants and antidepressants can result in augmentation.

Other medications

The selective estrogen receptor modulator raloxifene (Evista), 60 mg every other day, is effective in improving pain, improving fatigue, reducing tender-point count, and improving daily functioning in postmenopausal women with fibromyalgia.^[152] Modafinil (Provigil), approved for narcolepsy and shift-work sleep disorder, 100-200 mg in the morning, can improve fatigue and cognitive disturbances.^{[153, 154]}

A review of medical cannabis for the treatment of fibromyalgia by Habib and Artul concluded that the treatment had a significant favorable effect, with few adverse effects. The study included 26 patients, who used a mean dosage of 26 g per month, for a mean duration of 10.4 months. All the patients reported experiencing a significant improvement in every parameter on the Revised Fibromyalgia Impact Questionnaire after starting medical cannabis treatment, and 13 patients stopped taking any other medications for fibromyalgia. Eight patients experienced very mild adverse effects.^[155]

Preliminary data suggest that the synthetic cannabinoid nabilone (Cesamet), in doses escalating from 0.5 mg daily to 1 mg twice daily, improves pain and anxiety in fibromyalgia.^[156] Beta-adrenergic antagonists such as pindolol or propranolol (Inderal), given in low doses at bedtime, can also improve pain and agitation.^[157]

Sleep

Poor sleep worsens and perpetuates symptoms, so intensive treatment is indicated. Most patients understand little about the nature of sleep; therefore, instruct them on the basics of sleep and proper sleep hygiene. Providing this education is one of the most helpful interventions.^[158]

Dietary and behavioral changes that may be helpful include avoiding caffeine and large evening meals; avoiding alcohol is also helpful. Teach the patient basic relaxation techniques to use before bed. If urinary frequency is problematic, restrict fluids in the evenings.

It may be helpful for the patient to keep a sleep diary for 2 weeks before starting any new medications. The sleep diary provides useful information for choosing medications. The diary should include the following:

Medications taken
Time at which the patient went to bed
Approximate time of falling asleep
Number of awakenings
Number of times the patient got out of bed
General description of how rested the patient felt

Consider comorbid illnesses that may be present, such as restless legs syndrome, periodic limb-movement disorder, or sleep apnea. If these disorders are suspected, a sleep study may be needed.

Medications to improve sleep

If proper education and instruction on sleep hygiene and dietary changes fail to provide adequate improvement in the patient’s sleep, consider using appropriate medications. Sleep problems may be treated with the following:

Antidepressants (eg, trazodone, SSRIs, SNRIs, tricyclic antidepressants)
Anticonvulsants (eg, clonazepam, gabapentin, tiagabine, pregabalin)
Nonbenzodiazepine hypnotics (eg, zolpidem, zaleplon, eszopiclone)
Muscle relaxants (eg, cyclobenzaprine, tizanidine)
Dopamine agonists (eg, pramipexole, ropinirole)

Sleep-maintenance disorders are more difficult to manage than are sleep-onset problems. In general, antidepressants are most commonly used because of their effect on serotonin. Tricyclic antidepressants have the strongest evidence for efficacy. The criterion standard is amitriptyline, but many patients cannot tolerate this drug.

Trazodone is inexpensive, well-tolerated, and effective. It should be taken at 8 pm. The starting dose is 25 mg, If necessary, the dose can be slowly titrated upward. If the patient is not staying asleep, adding an SSRI may be helpful.

If the patient has concomitant restless legs syndrome or mitral valve prolapse, clonazepam may be the drug of choice. The starting dose is 0.125 or 0.25 mg taken at 8 pm. Titrate the dose to the lowest effective dose.

Tiagabine increases sleep efficiency with a marked increase in slow-wave sleep in healthy elderly patients. Tiagabine titrated from 2 mg to 12 mg may improve sleep maintenance in some patients.

Gabapentin may also aid in sleep maintenance.^[147]Evidence suggests that pregabalin, which is approved for use in fibromyalgia by the US Food and Drug Administration (FDA), is effective for improving sleep.^[159]

The dopamine agonist pramipexole (Mirapex) is FDA approved for the treatment of moderate to severe restless legs syndrome. This medication may aid in sleep maintenance in patients with fibromyalgia and restless legs syndrome. It is also under investigation as a treatment for fibromyalgia pain.^{[160, 157]}

Dietary Recommendations

Patients with fibromyalgia are generally interested in diet and are influenced heavily by information that promotes complementary and alternative approaches to this disorder; therefore, promote sound general nutrition, appropriate vitamin supplementation, bone health, and weight reduction, if needed.^{[161, 162]}

Physicians must acquaint themselves with the available research on diet and metabolism. Investigate the trend diets and make informed recommendations to each patient on an individual basis. Help patients set attainable goals for dietary modification.

Poor diet worsens the symptoms of fibromyalgia, possibly as a result of impaired glycolysis and carbohydrate metabolism. Dietary changes are essential to improving symptoms in such patients, but they are challenging to achieve.

Although many dietary choices can be made, some may be no healthier than the patient's existing diet. While no dietary or nutritional approach is universally accepted, increasing evidence reveals that some nutritional changes may improve the symptoms of fibromyalgia. Choose an approach that is nutritionally balanced and safe. Help the patient to set reasonable and attainable goals.^[161]

Have the patient keep a food journal for 2 weeks. Determine what foods the patient normally eats.

Slowly wean the patient off caffeine, because abruptly stopping caffeine will increase fatigue and pain, headaches, anxiety, and sleep disturbance. Some suggest that all alcohol must be avoided for at least 6 months; however, a patient with stable symptoms may consume no more than two alcoholic drinks a day.

Tobacco use should cease, as should the consumption of chemical-laden foods, aspartame, and monosodium glutamate (MSG). In some, but not all, cases, elimination of aspartame and MSG from the diet has resulted in patient improvement.^{[163, 164, 165]}

Most patients with fibromyalgia consume enormous amounts of carbohydrate-rich foods, suchas refined sugars and white flour, which may contribute to their symptoms. Some suggest a diet high in fresh vegetables, fish, and fiber. Green, leafy, and yellow vegetables are preferred because of their low carbohydrate content.

Choose fruits carefully; some are more glycemic than others. Fruits such as citrus fruits, apples, berries, cantaloupe, and peaches may be preferred.

The rate of carbohydrate absorption decreases if the patient combines starchy food with a food containing fiber or fat. Advise patients to avoid junk foods or processed snack foods, which usually contain large amounts of sugar or salt.

Patients with fibromyalgia produce more damaging free radicals than do healthy people, and they have a reduced antioxidant capacity. Normal cellular respiration produces free radicals that lead to oxidative stress. The antioxidant defense system normally keeps these free radicals in check. Dietary antioxidants consumed in foods are essential to increasing our antioxidant status and maintaining our antioxidant systems.

Vitamins (eg, C, E), minerals (eg, selenium, zinc), and phytochemicals are important dietary antioxidants. Vegetarian diets improve some symptoms, in association with an increased intestinal bacterial profile and increased antioxidant status; however, they may be difficult to maintain long term. A vegetarian diet rich in a variety of fruits, vegetables, and nuts may be of some benefit. Moderation may be the key to long-term compliance.

Deficiency of 25-hydroxyvitamin D is very common in patients with rheumatologic conditions and chronic pain and should be routinely sought. Low levels of vitamin D are not associated with chronic pain, however, and treatment with vitamin D does not reduce pain.

Other dietary measures used in fibromyalgia include the following:

Malic acid and magnesium combination
Antioxidants
Amino acids
Herbs and supplements

Consultations

Consultation with a rheumatologist experienced in the diagnosis and treatment of fibromyalgia is appropriate. In addition, a rheumatologist can assist in the differential diagnoses of chronic pain and fatigue syndromes and in the assessment of comorbid rheumatologic disorders.

Referral to a neurologist, dentist, or other specialist may be beneficial in patients with prominent regional pain disorders that coexist with fibromyalgia. Psychological counseling is useful. If a psychiatric disorder is suggested, consult a psychiatrist.

Long-Term Monitoring

Follow-up care in patients with fibromyalgia is greatly facilitated by the following:

Maintaining rapport
Encouraging compliance with exercise regimens
Paying attention to current psychological and physical stressors
Obtaining ongoing self-report questionnaire information that provides semiquantitative data concerning the patient's function, levels of pain and fatigue, and global self-assessment of how the patient is doing

Integrative Medicine

Integrative medicine (complementary and altenative medicine [CAM]) is popular in patients with fibromyalgia, in part due to medical skepticism (ie, doubt in the ability of conventional medical care to appreciably alter health status).^[166]Many physicians are ignorant of, if not overtly hostile toward, integrative medicine, and patients are often reluctant to inform their physician about their use of it. This can be dangerous because of unsuspected drug-to-drug interactions.

A practical approach includes the following:

Inquire about integrative medicine usage.
Refrain from expressing negative opinions if a particular integrative treatment is relatively inexpensive and appears to be safe.
Encourage whatever works in the context of the power of the placebo effect and promotion of self-efficacy for pain control.

Guidelines

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Media Gallery

A neurophysiologist's view of pain. Courtesy of Alan R. Light, PhD.
Tender points in fibromyalgia.
Pressure algometer (dolorimeter).
Biopsychosocial model of fibromyalgia.

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Author

Chad S Boomershine, MD, PhD, CPI, CPT Assistant Clinical Professor, Department of Medicine, Vanderbilt University School of Medicine; Principal Investigator, Clinical Research Solutions; Medical Director, Boomershine Wellness Centers, Elite Healthcare Alliance, Platinum Medical Group, and Spectrum Pain Clinic

Chad S Boomershine, MD, PhD, CPI, CPT is a member of the following medical societies: American College of Rheumatology, American Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Pfizer;<br/>Serve(d) as a speaker or a member of a speakers bureau for: Pfizer;.

Chief Editor

Herbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital

Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Acknowledgements

Lawrence H Brent, MD Associate Professor of Medicine, Jefferson Medical College of Thomas Jefferson University; Chair, Program Director, Department of Medicine, Division of Rheumatology, Albert Einstein Medical Center

Lawrence H Brent, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association of Immunologists, American College of Physicians, and American College of Rheumatology

Disclosure: Genentech Honoraria Speaking and teaching; Genentech Grant/research funds Other; Amgen Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; Abbott Immunology Honoraria Speaking and teaching; Takeda Honoraria Speaking and teaching; UCB Speaking and teaching; Omnicare Consulting fee Consulting; Centocor Consulting fee Consulting

Kristine M Lohr, MD, MS Professor, Department of Internal Medicine, Center for the Advancement of Women's Health and Division of Rheumatology, Director, Rheumatology Training Program, University of Kentucky College of Medicine

Kristine M Lohr, MD, MS is a member of the following medical societies: American College of Physicians and American College of Rheumatology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

John Buckner Winfield, MD Herman and Louise Smith Distinguished Professor of Medicine in Arthritis Emeritus, Department of Medicine, Senior Member, Neurosensory Disorders Center, University of North Carolina at Chapel Hill; Consulting Rheumatologist, Appalachian Regional Rheumatology

John Buckner Winfield, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Immunologists, American Clinical and Climatological Association, American College of Rheumatology, American Federation for Clinical Research, American Pain Society, American Society for Clinical Investigation, Association of American Physicians, and North Carolina Medical Society

Disclosure: Pfizer Honoraria Speaking and teaching; Forest Honoraria Speaking and teaching