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.^[104]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.^[105]

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.^[106]

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.^{[28, 35, 107, 108, 109, 110, 111, 112, 113]}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.^[114]

Poor sleep is virtually universal in fibromyalgia and contributes importantly to pain, depression, and fatigue. Accurate diagnosis and pharmacologic and nonpharmacologic management are essential.^{[115, 116, 117]}

Electrical neuromodulation techniques have shown benefit in fibromyalgia. These include transcutaneous electrical nerve stimulation, transcranial direct-current stimulation, and transcranial magnetic stimulation.^{[2, 118]}

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.

For more information on nonpharmacologic treatment, see Rehabilitation and Fibromyalgia.

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.^[119]

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.^{[120, 121]}

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.^[122]

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.^[112]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.^[123]

Pretreatment patient characteristics are important predictors of response to nonpharmacologic therapies.^[124]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.^[125]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.^[126]

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.^{[113, 127, 128]}

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.^[129]

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.^[130]

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.^[131]

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.^[131]

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).^[132] 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.^[133]

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.^[134]

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.^[135] 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. ^[104] ^[136] 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. ^[137]

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).^[117] 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),^[138] 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.^[139] Because of its potential for abuse, dependence, and diversion (date rape), it is available only through a centralized pharmacy (1-866-997-3688).

Antidepressants

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),^[140]or duloxetine (Cymbalta).^{[141, 142, 143]}

Milnacipran has been approved for use in fibromyalgia by the FDA. Duloxetine has been shown to improve pain in fibromyalgia irrespective of comorbid depression^[144]and is currently approved by the FDA for pain in fibromyalgia. SNRIs can cause nausea, so they should be taken with food.

Low-dose TCAs have proved to have short-term efficacy in patients with fibromyalgia. A systematic review and network meta-analysis that compared the TCA amitriptyline with pregabalin, duloxetine, and milnacipran concluded that amitriptyline was not significantly different from placebo for relief of depression but showed higher efficacy and acceptability in improving sleep, fatigue, and health-related quality of life outcomes.^[145]However, adverse anticholinergic effects (eg, dry mouth, drowsiness, weight gain) often limit patient acceptance/tolerance of TCAs.

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.^[146]However, patients taking combinations of serotonin-active drugs should be closely monitored for the development of serotonin syndrome,^[147]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.^{[148, 149]}

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.^{[148, 149]}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^[150]and pregabalin (Lyrica).^{[151, 152, 126]} 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^[153] as well as gabapentin with venlafaxine,^[154] 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.^[155] Modafinil (Provigil), approved for narcolepsy and shift-work sleep disorder, 100-200 mg in the morning, can improve fatigue and cognitive disturbances.^{[156, 157]}

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.^[158]

Similarly, a prospective cohort study by Hershkovich et al suggests a potentially significant role of cannabis in women with treatment‐resistant fibromyalgia. In 30 women aged 18-70 years who received 20 g per month, cannabis treatment for 30 days resulted in a marked improvement in general quality of life, general health, physical health, and psychological domain (P < 0.01 for all measures).^[159]

Preliminary data suggested 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.^[160]However, a subsequent Cochrane review concluded that the evidence found did not support the benefit of nabilone for fibromyalgia, and that the drug was poorly tolerated in this population.^[161]

Beta-adrenergic antagonists such as pindolol or propranolol (Inderal), given in low doses at bedtime, may help improve pain and agitation.^[162]

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.^[163]

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.^[150]Evidence suggests that pregabalin, which is approved for use in fibromyalgia by the US Food and Drug Administration (FDA), is effective for improving sleep.^[164]

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.^{[165, 162]}

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.^{[166, 167]}

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.^[166]

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.^{[168, 169, 170]}

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. Vitamin D supplementation may improve psychological outcomes and quality of life in patients with fibromyalgia.^[171]

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).^[172]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

López-Pousa S, Garre-Olmo J, de Gracia M, Ribot J, Calvó-Perxas L, Vilalta-Franch J. Development of a multidimensional measure of fibromyalgia symptomatology: The comprehensive rating scale for fibromyalgia symptomatology. J Psychosom Res. 2013 May. 74(5):384-92. [QxMD MEDLINE Link].
Giorgi V, Bazzichi L, Batticciotto A, Pellegrino G, Di Franco M, Sirotti S, et al. Fibromyalgia: one year in review 2023. Clin Exp Rheumatol. 2023 Jun. 41 (6):1205-1213. [QxMD MEDLINE Link].
Borchers AT, Gershwin ME. Fibromyalgia: A Critical and Comprehensive Review. Clin Rev Allergy Immunol. 2015 Oct. 49 (2):100-51. [QxMD MEDLINE Link].
Yunus MB. Fibromyalgia and overlapping disorders: the unifying concept of central sensitivity syndromes. Semin Arthritis Rheum. 2007 Jun. 36(6):339-56. [QxMD MEDLINE Link].
Sawaddiruk P, Paiboonworachat S, Chattipakorn N, Chattipakorn SC. Alterations of brain activity in fibromyalgia patients. J Clin Neurosci. 2017 Apr. 38:13-22. [QxMD MEDLINE Link].
Gracely RH, Petzke F, Wolf JM, Clauw DJ. Functional magnetic resonance imaging evidence of augmented pain processing in fibromyalgia. Arthritis Rheum. 2002 May. 46(5):1333-43. [QxMD MEDLINE Link].
Wolfe F, Cathey MA, Kleinheksel SM. Fibrositis (Fibromyalgia) in rheumatoid arthritis. J Rheumatol. 1984 Dec. 11(6):814-8. [QxMD MEDLINE Link].
Buskila D, Press J, Abu-Shakra M. Fibromyalgia in systemic lupus erythematosus: prevalence and clinical implications. Clin Rev Allergy Immunol. 2003 Aug. 25(1):25-8. [QxMD MEDLINE Link].
Thompson ME, Barkhuizen A. Fibromyalgia, hepatitis C infection, and the cytokine connection. Curr Pain Headache Rep. 2003 Oct. 7(5):342-7. [QxMD MEDLINE Link].
Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990 Feb. 33(2):160-72. [QxMD MEDLINE Link].
Katz RS, Wolfe F, Michaud K. Fibromyalgia diagnosis: a comparison of clinical, survey, and American College of Rheumatology criteria. Arthritis Rheum. 2006 Jan. 54(1):169-76. [QxMD MEDLINE Link].
Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). 2010 May. 62(5):600-10. [QxMD MEDLINE Link].
Observations with cases illustrative of a new, simple, and expeditious mode of curing rheumatism and sprains. Balfour W. J Lond Med Phys. 1824. 51:446-62.
Beard G. Neurasthenia, or nervous exhaustion. J Boston Med Surg. 1869. 80:217-22.
Gowers WR. Lumbago: Its lessons and analogues. Br Med J. 1904. 1:117-21.
Chaitow L. Fibromyalgia and Muscle Pain. Thorsons Pub; 1995. 1-205.
Yunus M, Masi AT, Calabro JJ, Miller KA, Feigenbaum SL. Primary fibromyalgia (fibrositis): clinical study of 50 patients with matched normal controls. Semin Arthritis Rheum. 1981 Aug. 11(1):151-71. [QxMD MEDLINE Link].
Schmidt-Wilcke T, Diers M. New Insights into the Pathophysiology and Treatment of Fibromyalgia. Biomedicines. 2017 May 13. 5 (2):[QxMD MEDLINE Link]. [Full Text].
Clauw DJ. Fibromyalgia: more than just a musculoskeletal disease. Am Fam Physician. 1995 Sep 1. 52(3):843-51, 853-4. [QxMD MEDLINE Link].
Merskey H. Classification of chronic pain: Description of chronic pain syndromes and definitions of pain terms. Pain. 1986. Suppl 3:S217.
Pillemer SR, Bradley LA, Crofford LJ, Moldofsky H, Chrousos GP. The neuroscience and endocrinology of fibromyalgia. Arthritis Rheum. 1997 Nov. 40(11):1928-39. [QxMD MEDLINE Link].
Crofford LJ. The hypothalamic-pituitary-adrenal stress axis in fibromyalgia and chronic fatigue syndrome. Z Rheumatol. 1998. 57 Suppl 2:67-71. [QxMD MEDLINE Link].
Martinez-Lavin M. Biology and therapy of fibromyalgia. Stress, the stress response system, and fibromyalgia. Arthritis Res Ther. 2007. 9(4):216. [QxMD MEDLINE Link].
Tanriverdi F, Karaca Z, Unluhizarci K, et al. The hypothalamo-pituitary-adrenal axis in chronic fatigue syndrome and fibromyalgia syndrome. Stress. 2007 Mar. 10(1):13-25. [QxMD MEDLINE Link].
van Middendorp H, Lumley MA, Jacobs JW, Bijlsma JW, Geenen R. The effects of anger and sadness on clinical pain reports and experimentally-induced pain thresholds in women with and without fibromyalgia. Arthritis Care Res (Hoboken). 2010 Oct. 62(10):1370-6. [QxMD MEDLINE Link].
Jones KD, Deodhar P, Lorentzen A, Bennett RM, Deodhar AA. Growth hormone perturbations in fibromyalgia: a review. Semin Arthritis Rheum. 2007 Jun. 36(6):357-79. [QxMD MEDLINE Link].
Umeda M, Corbin LW, Maluf KS. Preliminary investigation of absent nociceptive flexion reflex responses among more symptomatic women with fibromyalgia syndrome. Rheumatol Int. 2013 Apr 4. [QxMD MEDLINE Link].
Clauw DJ. Fibromyalgia: update on mechanisms and management. J Clin Rheumatol. 2007 Apr. 13(2):102-9. [QxMD MEDLINE Link].
Staud R, Robinson ME, Vierck CJ Jr, et al. Diffuse noxious inhibitory controls (DNIC) attenuate temporal summation of second pain in normal males but not in normal females or fibromyalgia patients. Pain. 2003 Jan. 101(1-2):167-74. [QxMD MEDLINE Link].
Staud R, Spaeth M. Psychophysical and neurochemical abnormalities of pain processing in fibromyalgia. CNS Spectr. 2008 Mar. 13(3 Suppl 5):12-7. [QxMD MEDLINE Link].
Wood PB, Schweinhardt P, Jaeger E, et al. Fibromyalgia patients show an abnormal dopamine response to pain. Eur J Neurosci. 2007 Jun. 25(12):3576-82. [QxMD MEDLINE Link].
Sarchielli P, Di Filippo M, Nardi K, Calabresi P. Sensitization, glutamate, and the link between migraine and fibromyalgia. Curr Pain Headache Rep. 2007 Oct. 11(5):343-51. [QxMD MEDLINE Link].
Diatchenko L, Slade GD, Nackley AG, et al. Genetic basis for individual variations in pain perception and the development of a chronic pain condition. Hum Mol Genet. 2005 Jan 1. 14(1):135-43. [QxMD MEDLINE Link].
Docampo E, Escaramís G, Gratacòs M, Villatoro S, Puig A, Kogevinas M, et al. Genome-wide analysis of single nucleotide polymorphisms and copy number variants in fibromyalgia suggest a role for the central nervous system. Pain. 2014 Jun. 155 (6):1102-9. [QxMD MEDLINE Link].
Clauw DJ. Pharmacotherapy for patients with fibromyalgia. J Clin Psychiatry. 2008. 69 Suppl 2:25-9. [QxMD MEDLINE Link].
Winfield JB. Psychological determinants of fibromyalgia and related syndromes. Curr Rev Pain. 2000. 4(4):276-86. [QxMD MEDLINE Link].
Tander B, Gunes S, Boke O, et al. Polymorphisms of the serotonin-2A receptor and catechol-O-methyltransferase genes: a study on fibromyalgia susceptibility. Rheumatol Int. 2008 May. 28(7):685-91. [QxMD MEDLINE Link].
Russell IJ, Orr MD, Littman B, et al. Elevated cerebrospinal fluid levels of substance P in patients with the fibromyalgia syndrome. Arthritis Rheum. 1994 Nov. 37(11):1593-601. [QxMD MEDLINE Link].
Griep EN, Boersma JW, de Kloet ER. Altered reactivity of the hypothalamic-pituitary-adrenal axis in the primary fibromyalgia syndrome. J Rheumatol. 1993 Mar. 20(3):469-74. [QxMD MEDLINE Link].
Crofford LJ. Neuroendocrine aspects of fibromyalgia. J Musculoskelet Pain. 1994. 2:125-33.
Cuatrecasas G, Riudavets C, Güell MA, Nadal A. Growth hormone as concomitant treatment in severe fibromyalgia associated with low IGF-1 serum levels. A pilot study. BMC Musculoskelet Disord. 2007 Nov 30. 8:119. [QxMD MEDLINE Link]. [Full Text].
Albrecht DS, Forsberg A, Sandström A, Bergan C, Kadetoff D, Protsenko E, et al. Brain glial activation in fibromyalgia - A multi-site positron emission tomography investigation. Brain Behav Immun. 2018 Sep 14. [QxMD MEDLINE Link]. [Full Text].
Glass JM. Fibromyalgia and cognition. J Clin Psychiatry. 2008. 69 Suppl 2:20-4. [QxMD MEDLINE Link].
Glass JM, Williams DA, Fernandez-Sanchez ML, Kairys A, Barjola P, Heitzeg MM, et al. Executive function in chronic pain patients and healthy controls: different cortical activation during response inhibition in fibromyalgia. J Pain. 2011 Dec. 12(12):1219-29. [QxMD MEDLINE Link].
Lue FA. Sleep and fibromyalgia. J Musculoskelet Pain. 1994. 2:89-100.
WebSciences International and Sleep Research Society (United States). Basics of Sleep Behavior. Sleep Research Society. Available at http://www.sleepsources.org/uploads/sleepsyllabus/. 1997; Accessed: September 5, 2018.
Goebel A, Krock E, Gentry C, Israel MR, Jurczak A, Urbina CM, et al. Passive transfer of fibromyalgia symptoms from patients to mice. J Clin Invest. 2021 Jul 1. 131 (13):[QxMD MEDLINE Link].
Tracey KJ. From human to mouse and back offers hope for patients with fibromyalgia. J Clin Invest. 2021 Jul 1. 131 (13):[QxMD MEDLINE Link].
Pinto AM, Luís M, Geenen R, Palavra F, Lumley MA, Ablin JN, et al. Neurophysiological and psychosocial mechanisms of fibromyalgia: A comprehensive review and call for an integrative model. Neurosci Biobehav Rev. 2023 Aug. 151:105235. [QxMD MEDLINE Link].
Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977 Apr 8. 196(4286):129-36. [QxMD MEDLINE Link].
Arnold LM, Hudson JI, Hess EV, Ware AE, Fritz DA, Auchenbach MB, et al. Family study of fibromyalgia. Arthritis Rheum. 2004 Mar. 50(3):944-52. [QxMD MEDLINE Link].
Olson J. Mapping Genes for Fibromyalgia. National Institute of Arthritis and Musculoskeletal and Skin Diseases; Aug 2004. Spotlight on Research, Fibromyalgia: Summaries of Research. [Full Text].
Diatchenko L, Nackley AG, Slade GD, et al. Idiopathic pain disorders--pathways of vulnerability. Pain. 2006 Aug. 123(3):226-30. [QxMD MEDLINE Link].
Buskila D, Sarzi-Puttini P. Biology and therapy of fibromyalgia. Genetic aspects of fibromyalgia syndrome. Arthritis Res Ther. Jul 28 2006. 8(5):218.
Ovrom EA, Mostert KA, Khakhkhar S, McKee DP, Yang P, Her YF. A Comprehensive Review of the Genetic and Epigenetic Contributions to the Development of Fibromyalgia. Biomedicines. 2023 Apr 7. 11 (4):[QxMD MEDLINE Link]. [Full Text].
Offenbaecher M, Bondy B, de Jonge S, Glatzeder K, Krüger M, Schoeps P, et al. Possible association of fibromyalgia with a polymorphism in the serotonin transporter gene regulatory region. Arthritis Rheum. 1999 Nov. 42(11):2482-8. [QxMD MEDLINE Link].
Diatchenko L, Nackley AG, Slade GD, Bhalang K, Belfer I, Max MB, et al. Catechol-O-methyltransferase gene polymorphisms are associated with multiple pain-evoking stimuli. Pain. 2006 Dec 5. 125(3):216-24. [QxMD MEDLINE Link].
Fillingim RB, Maixner W. Gender differences in the responses to noxious stimuli. Pain Forum. 1995. 4:209-221.
Moldofsky H, Scarisbrick P, England R, et al. Musculosketal symptoms and non-REM sleep disturbance in patients with "fibrositis syndrome" and healthy subjects. Psychosom Med. 1975 Jul-Aug. 37(4):341-51. [QxMD MEDLINE Link].
Schrader H, Obelieniene D, Bovim G, Surkiene D, Mickeviciene D, Miseviciene I, et al. Natural evolution of late whiplash syndrome outside the medicolegal context. Lancet. 1996 May 4. 347(9010):1207-11. [QxMD MEDLINE Link].
Buskila D, Neumann L, Vaisberg G, Alkalay D, Wolfe F. Increased rates of fibromyalgia following cervical spine injury. A controlled study of 161 cases of traumatic injury. Arthritis Rheum. 1997 Mar. 40(3):446-52. [QxMD MEDLINE Link].
Obelieniene D, Schrader H, Bovim G, Miseviciene I, Sand T. Pain after whiplash: a prospective controlled inception cohort study. J Neurol Neurosurg Psychiatry. 1999 Mar. 66(3):279-83. [QxMD MEDLINE Link].
Tishler M, Levy O, Maslakov I, Bar-Chaim S, Amit-Vazina M. Neck injury and fibromyalgia-- are they really associated?. J Rheumatol. 2006 Jun. 33(6):1183-5. [QxMD MEDLINE Link].
Shir Y, Pereira JX, Fitzcharles MA. Whiplash and fibromyalgia: an ever-widening gap. J Rheumatol. 2006 Jun. 33(6):1045-7. [QxMD MEDLINE Link].
Van Houdenhove B, Egle UT. Fibromyalgia: a stress disorder? Piecing the biopsychosocial puzzle together. Psychother Psychosom. 2004 Sep-Oct. 73(5):267-75. [QxMD MEDLINE Link].
Van Houdenhove B, Luyten P. Beyond dualism: the role of life stress in chronic pain. Pain. 2005 Jan. 113(1-2):238-9; discussion 240-2. [QxMD MEDLINE Link].
Wolfe F, Ross K, Anderson J, Russell IJ, Hebert L. The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum. 1995 Jan. 38(1):19-28. [QxMD MEDLINE Link].
Moldofsky H, Scarisbrick P. Induction of neurasthenic musculoskeletal pain syndrome by selective sleep stage deprivation. Psychosom Med. 1976 Jan-Feb. 38(1):35-44. [QxMD MEDLINE Link].
Crombez G, Eccleston C, Van den Broeck A, et al. Hypervigilance to pain in fibromyalgia: the mediating role of pain intensity and catastrophic thinking about pain. Clin J Pain. 2004 Mar-Apr. 20(2):98-102. [QxMD MEDLINE Link].
Keefe FJ, Lefebvre JC, Maixner W, Salley AN Jr, Caldwell DS. Self-efficacy for arthritis pain: relationship to perception of thermal laboratory pain stimuli. Arthritis Care Res. 1997 Jun. 10(3):177-84. [QxMD MEDLINE Link].
Gracely RH, Geisser ME, Giesecke T, Grant MA, Petzke F, Williams DA, et al. Pain catastrophizing and neural responses to pain among persons with fibromyalgia. Brain. 2004 Apr. 127:835-43. [QxMD MEDLINE Link].
Bradley LA. Psychiatric comorbidity in fibromyalgia. Curr Pain Headache Rep. 2005 Apr. 9(2):79-86. [QxMD MEDLINE Link].
Arnold LM, Hudson JI, Keck PE, Auchenbach MB, Javaras KN, Hess EV. Comorbidity of fibromyalgia and psychiatric disorders. J Clin Psychiatry. 2006 Aug. 67(8):1219-25. [QxMD MEDLINE Link].
Giesecke T, Williams DA, Harris RE, Cupps TR, Tian X, Tian TX, et al. Subgrouping of fibromyalgia patients on the basis of pressure-pain thresholds and psychological factors. Arthritis Rheum. 2003 Oct. 48(10):2916-22. [QxMD MEDLINE Link].
Giesecke T, Gracely RH, Williams DA, Geisser ME, Petzke FW, Clauw DJ. The relationship between depression, clinical pain, and experimental pain in a chronic pain cohort. Arthritis Rheum. 2005 May. 52(5):1577-84. [QxMD MEDLINE Link].
Fassbender K, Samborsky W, Kellner M, Müller W, Lautenbacher S. Tender points, depressive and functional symptoms: comparison between fibromyalgia and major depression. Clin Rheumatol. 1997 Jan. 16(1):76-9. [QxMD MEDLINE Link].
Hoffman DL, Dukes EM. The health status burden of people with fibromyalgia: a review of studies that assessed health status with the SF-36 or the SF-12. Int J Clin Pract. 2008 Jan. 62(1):115-26. [QxMD MEDLINE Link].
Hassett AL. Psychosocial aspects of fibromyalgia: psychological stress, psychiatric morbidity, and personality subgroups. 2008. pp 55-61.
McBeth J, Macfarlane GJ, Benjamin S, Morris S, Silman AJ. The association between tender points, psychological distress, and adverse childhood experiences: a community-based study. Arthritis Rheum. 1999 Jul. 42(7):1397-404. [QxMD MEDLINE Link].
Buchwald D, Umali P, Umali J, Kith P, Pearlman T, Komaroff AL. Chronic fatigue and the chronic fatigue syndrome: prevalence in a Pacific Northwest health care system. Ann Intern Med. 1995 Jul 15. 123(2):81-8. [QxMD MEDLINE Link].
Pawlikowska T, Chalder T, Hirsch SR, Wallace P, Wright DJ, Wessely SC. Population based study of fatigue and psychological distress. BMJ. 1994 Mar 19. 308(6931):763-6. [QxMD MEDLINE Link].
White LA, Birnbaum HG, Kaltenboeck A, et al. Employees with fibromyalgia: medical comorbidity, healthcare costs, and work loss. J Occup Environ Med. 2008 Jan. 50(1):13-24. [QxMD MEDLINE Link].
Arnold LM, Crofford LJ, Mease PJ, et al. Patient perspectives on the impact of fibromyalgia. Patient Educ Couns. 2008 Oct. 73(1):114-20. [QxMD MEDLINE Link]. [Full Text].
Vincent A, Lahr BD, Wolfe F, et al. Prevalence of fibromyalgia: a population-based study in Olmsted County, Minnesota, utilizing the Rochester Epidemiology Project. Arthritis Care Res (Hoboken). 2013 May. 65(5):786-92. [QxMD MEDLINE Link].
Branco JC, Bannwarth B, Failde I, et al. Prevalence of fibromyalgia: a survey in five European countries. Semin Arthritis Rheum. 2010 Jun. 39(6):448-53. [QxMD MEDLINE Link].
Guermazi M, Ghroubi S, Sellami M, et al. [Fibromyalgia prevalence in Tunisia]. Tunis Med. 2008 Sep. 86(9):806-11. [QxMD MEDLINE Link].
White KP, Speechley M, Harth M, Ostbye T. The London Fibromyalgia Epidemiology Study: the prevalence of fibromyalgia syndrome in London, Ontario. J Rheumatol. 1999 Jul. 26(7):1570-6. [QxMD MEDLINE Link].
Assumpção A, Cavalcante AB, Capela CE, et al. Prevalence of fibromyalgia in a low socioeconomic status population. BMC Musculoskelet Disord. 2009 Jun 8. 10:64. [QxMD MEDLINE Link]. [Full Text].
Santos AM, Burti JS, Lopes JB, Scazufca M, Marques AP, Pereira RM. Prevalence of fibromyalgia and chronic widespread pain in community-dwelling elderly subjects living in São Paulo, Brazil. Maturitas. 2010 Nov. 67(3):251-5. [QxMD MEDLINE Link].
Gansky SA, Plesh O. Widespread pain and fibromyalgia in a biracial cohort of young women. J Rheumatol. 2007 Apr. 34(4):810-7. [QxMD MEDLINE Link].
Neumann L, Buskila D. Ethnocultural and educational differences in Israeli women correlate with pain perception in fibromyalgia. J Rheumatol. 1998 Jul. 25(7):1369-73. [QxMD MEDLINE Link].
Felson DT. Comparing the prevalence of rheumatic diseases in China with the rest of the world. Arthritis Res Ther. 2008. 10(1):106. [QxMD MEDLINE Link]. [Full Text].
Ferrari R, Russell AS. A questionnaire using the modified 2010 American College of Rheumatology criteria for fibromyalgia: specificity and sensitivity in clinical practice. J Rheumatol. 2013 Sep. 40(9):1590-5. [QxMD MEDLINE Link].
Michels H, Gerhold K, Hafner R, et al. [Juvenile fibromyalgia syndrome]. Schmerz. 2008 Jun. 22(3):339-48. [QxMD MEDLINE Link].
Palstam A, Bjersing JL, Mannerkorpi K. Which aspects of health differ between working and nonworking women with fibromyalgia? A cross-sectional study of work status and health. BMC Public Health. 2012 Dec 14. 12:1076. [QxMD MEDLINE Link]. [Full Text].
Turk DC, Okifuji A, Sinclair JD, et al. Pain, disability, and physical functioning in subgroups of patients with fibromyalgia. J Rheumatol. 1996 Jul. 23(7):1255-62. [QxMD MEDLINE Link].
Turk DC, Okifuji A, Sinclair JD, et al. Differential responses by psychosocial subgroups of fibromyalgia syndrome patients to an interdisciplinary treatment. Arthritis Care Res. 1998 Oct. 11(5):397-404. [QxMD MEDLINE Link].
Dreyer L, Kendall S, Danneskiold-Samsoe B, Bartels EM, Bliddal H. Mortality in a cohort of Danish patients with fibromyalgia: increased frequency of suicide. Arthritis Rheum. 2010 Oct. 62(10):3101-8. [QxMD MEDLINE Link].
Stephens RJ, Hopwood P, Girling DJ, Machin D. Randomized trials with quality of life endpoints: are doctors' ratings of patients' physical symptoms interchangeable with patients' self-ratings?. Qual Life Res. 1997 Apr. 6(3):225-36. [QxMD MEDLINE Link].
Wolfe F, Clauw DJ, Fitzcharles MA, et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J Rheumatol. 2011 Jun. 38(6):1113-22. [QxMD MEDLINE Link].
Okifuji A, Turk DC, Sinclair JD, Starz TW, Marcus DA. A standardized manual tender point survey. I. Development and determination of a threshold point for the identification of positive tender points in fibromyalgia syndrome. J Rheumatol. 1997 Feb. 24(2):377-83. [QxMD MEDLINE Link].
Fan A, Tournadre A, Pereira B, Tatar Z, Couderc M, Malochet-Guinamand S, et al. Performance of Fibromyalgia Rapid Screening Tool (FiRST) to detect fibromyalgia syndrome in rheumatic diseases. Rheumatology (Oxford). 2016 Jun 15. [QxMD MEDLINE Link]. [Full Text].
Pincus T, Yazici Y, Bergman M. Development of a multi-dimensional health assessment questionnaire (MDHAQ) for the infrastructure of standard clinical care. Clin Exp Rheumatol. 2005 Sep-Oct. 23(5 Suppl 39):S19-28. [QxMD MEDLINE Link].
[Guideline] Fitzcharles MA, Ste-Marie PA, Goldenberg DL, Pereira JX, Abbey S, Choinière M, et al. 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary. Pain Res Manag. 2013 May-Jun. 18 (3):119-26. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Macfarlane GJ, Kronisch C, Dean LE, Atzeni F, Häuser W, Fluß E, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis. 2017 Feb. 76 (2):318-328. [QxMD MEDLINE Link].
Wood PB. Treating comorbidities in fibromyalgia. Pain Pract. 2008. 18(1):pp 42-53.
Turk DC, Vierck CJ, Scarbrough E, et al. Fibromyalgia: combining pharmacological and nonpharmacological approaches to treating the person, not just the pain. J Pain. 2008 Feb. 9(2):99-104. [QxMD MEDLINE Link].
Staud R. Treatment of fibromyalgia and its symptoms. Expert Opin Pharmacother. 2007 Aug. 8(11):1629-42. [QxMD MEDLINE Link].
Sarzi-Puttini P, Buskila D, Carrabba M, et al. Treatment strategy in fibromyalgia syndrome: where are we now?. Semin Arthritis Rheum. 2008 Jun. 37(6):353-65. [QxMD MEDLINE Link].
Carville SF, Arendt-Nielsen S, Bliddal H, et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis. 2008 Apr. 67(4):536-41. [QxMD MEDLINE Link].
Goldenberg DL. Pharmacological treatment of fibromyalgia and other chronic musculoskeletal pain. Best Pract Res Clin Rheumatol. 2007 Jun. 21(3):499-511. [QxMD MEDLINE Link].
Goldenberg DL. Multidisciplinary modalities in the treatment of fibromyalgia. J Clin Psychiatry. 2008. 69 Suppl 2:30-4. [QxMD MEDLINE Link].
Burckhardt CS. Multidisciplinary approaches for management of fibromyalgia. Curr Pharm Des. 2006. 12(1):59-66. [QxMD MEDLINE Link].
Häuser W, Bernardy K, Arnold B, Offenbächer M, Schiltenwolf M. Efficacy of multicomponent treatment in fibromyalgia syndrome: a meta-analysis of randomized controlled clinical trials. Arthritis Rheum. 2009 Feb 15. 61(2):216-24. [QxMD MEDLINE Link].
Benca RM, Ancoli-Israel S, Moldofsky H. Special considerations in insomnia diagnosis and management: depressed, elderly, and chronic pain populations. J Clin Psychiatry. 2004. 65 Suppl 8:26-35. [QxMD MEDLINE Link].
Bigatti SM, Hernandez AM, Cronan TA, et al. Sleep disturbances in fibromyalgia syndrome: relationship to pain and depression. Arthritis Rheum. 2008 Jul 15. 59(7):961-7. [QxMD MEDLINE Link].
Moldofsky H. The significance, assessment, and management of nonrestorative sleep in fibromyalgia syndrome. CNS Spectr. 2008 Mar. 13(3 Suppl 5):22-6. [QxMD MEDLINE Link].
Cheng YC, Hsiao CY, Su MI, Chiu CC, Huang YC, Huang WL. Treating fibromyalgia with electrical neuromodulation: A systematic review and meta-analysis. Clin Neurophysiol. 2023 Apr. 148:17-28. [QxMD MEDLINE Link].
Stephens S, Feldman BM, Bradley N, Schneiderman J, Wright V, Singh-Grewal D, et al. Feasibility and effectiveness of an aerobic exercise program in children with fibromyalgia: results of a randomized controlled pilot trial. Arthritis Rheum. 2008 Oct 15. 59(10):1399-406. [QxMD MEDLINE Link].
Kashikar-Zuck S, Cunningham N, Sil S, Bromberg MH, Lynch-Jordan AM, Strotman D, et al. Long-term outcomes of adolescents with juvenile-onset fibromyalgia in early adulthood. Pediatrics. 2014 Mar. 133(3):e592-600. [QxMD MEDLINE Link].
Kelly J. Teenagers With Fibromyalgia Unlikely to 'Outgrow' the Pain. Medscape Medical News. Available at http://www.medscape.com/viewarticle/821275. Accessed: March 1, 2014.
Upadhyaya HP, Arnold LM, Alaka K, Qiao M, Williams D, Mehta R. Efficacy and safety of duloxetine versus placebo in adolescents with juvenile fibromyalgia: results from a randomized controlled trial. Pediatr Rheumatol Online J. 2019 May 28. 17 (1):27. [QxMD MEDLINE Link]. [Full Text].
Thieme K, Flor H, Turk DC. Psychological pain treatment in fibromyalgia syndrome: efficacy of operant behavioural and cognitive behavioural treatments. Arthritis Res Ther. 2006. 8(4):R121. [QxMD MEDLINE Link].
Thieme K, Turk DC, Flor H. Responder criteria for operant and cognitive-behavioral treatment of fibromyalgia syndrome. Arthritis Rheum. 2007 Jun 15. 57(5):830-6. [QxMD MEDLINE Link].
Häuser W, Bernardy K, Uçeyler N, Sommer C. Treatment of fibromyalgia syndrome with antidepressants: a meta-analysis. JAMA. 2009 Jan 14. 301(2):198-209. [QxMD MEDLINE Link].
Arnold LM, Sarzi-Puttini P, Arsenault P, Khan T, Bhadra Brown P, Clair A, et al. Efficacy and Safety of Pregabalin in Patients with Fibromyalgia and Comorbid Depression Taking Concurrent Antidepressant Medication: A Randomized, Placebo-controlled Study. J Rheumatol. 2015 Jul. 42 (7):1237-44. [QxMD MEDLINE Link].
Jones KD, Adams D, Winters-Stone K, Burckhardt CS. A comprehensive review of 46 exercise treatment studies in fibromyalgia (1988-2005). Health Qual Life Outcomes. 2006 Sep 25. 4:67. [QxMD MEDLINE Link].
Busch AJ, Schachter CL, Overend TJ, et al. Exercise for fibromyalgia: a systematic review. J Rheumatol. 2008 Jun. 35(6):1130-44. [QxMD MEDLINE Link].
Munguía-Izquierdo D, Legaz-Arrese A. Assessment of the effects of aquatic therapy on global symptomatology in patients with fibromyalgia syndrome: a randomized controlled trial. Arch Phys Med Rehabil. 2008 Dec. 89(12):2250-7. [QxMD MEDLINE Link].
Sawynok J, Lynch ME. Qigong and Fibromyalgia circa 2017. Medicines (Basel). 2017 Jun 6. 4 (2):[QxMD MEDLINE Link]. [Full Text].
Wang C, Schmid CH, Fielding RA, Harvey WF, Reid KF, Price LL, et al. Effect of tai chi versus aerobic exercise for fibromyalgia: comparative effectiveness randomized controlled trial. BMJ. 2018 Mar 21. 360:k851. [QxMD MEDLINE Link]. [Full Text].
Living with Fibromyalgia, Drugs Approved to Manage Pain. U.S. Food and Drug Administration. Available at http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm107802.htm#approved. January 31, 2014; Accessed: July 30, 216.
Lee YH, Song GG. Comparative efficacy and tolerability of duloxetine, pregabalin, and milnacipran for the treatment of fibromyalgia: a Bayesian network meta-analysis of randomized controlled trials. Rheumatol Int. 2016 May. 36 (5):663-72. [QxMD MEDLINE Link].
Cuatrecasas G, Alegre C, Casanueva FF. GH/IGF1 axis disturbances in the fibromyalgia syndrome: is there a rationale for GH treatment?. Pituitary. 2013 Apr 9. [QxMD MEDLINE Link].
Winfield JB. Pain and arthritis. N C Med J. 2007 Nov-Dec. 68(6):444-6. [QxMD MEDLINE Link].
MacLean AJ, Schwartz TL. Tramadol for the treatment of fibromyalgia. Expert Rev Neurother. 2015 May. 15 (5):469-75. [QxMD MEDLINE Link].
Peng X, Robinson RL, Mease P, Kroenke K, Williams DA, Chen Y, et al. Long-term evaluation of opioid treatment in fibromyalgia. Clin J Pain. 2015 Jan. 31 (1):7-13. [QxMD MEDLINE Link].
Scharf MB, Hauck M, Stover R, et al. Effect of gamma-hydroxybutyrate on pain, fatigue, and the alpha sleep anomaly in patients with fibromyalgia. Preliminary report. J Rheumatol. 1998 Oct. 25(10):1986-90. [QxMD MEDLINE Link].
Russell IJ, Perkins AT, Michalek JE. Sodium oxybate relieves pain and improves function in fibromyalgia syndrome: a randomized, double-blind, placebo-controlled, multicenter clinical trial. Arthritis Rheum. 2009 Jan. 60(1):299-309. [QxMD MEDLINE Link].
Gendreau RM, Thorn MD, Gendreau JF, Kranzler JD, Ribeiro S, Gracely RH, et al. Efficacy of milnacipran in patients with fibromyalgia. J Rheumatol. 2005 Oct. 32(10):1975-85. [QxMD MEDLINE Link].
Arnold LM, Rosen A, Pritchett YL, D'Souza DN, Goldstein DJ, Iyengar S, et al. A randomized, double-blind, placebo-controlled trial of duloxetine in the treatment of women with fibromyalgia with or without major depressive disorder. Pain. 2005 Dec 15. 119(1-3):5-15. [QxMD MEDLINE Link].
Arnold LM, Pritchett YL, D'Souza DN, Kajdasz DK, Iyengar S, Wernicke JF. Duloxetine for the treatment of fibromyalgia in women: pooled results from two randomized, placebo-controlled clinical trials. J Womens Health (Larchmt). 2007 Oct. 16(8):1145-56. [QxMD MEDLINE Link].
Arnold LM. Duloxetine and other antidepressants in the treatment of patients with fibromyalgia. Pain Med. 2007 Sep. 8 Suppl 2:S63-74. [QxMD MEDLINE Link].
Russell IJ, Mease PJ, Smith TR, Kajdasz DK, Wohlreich MM, Detke MJ, et al. Efficacy and safety of duloxetine for treatment of fibromyalgia in patients with or without major depressive disorder: Results from a 6-month, randomized, double-blind, placebo-controlled, fixed-dose trial. Pain. 2008 Jun. 136(3):432-44. [QxMD MEDLINE Link].
Farag HM, Yunusa I, Goswami H, Sultan I, Doucette JA, Eguale T. Comparison of Amitriptyline and US Food and Drug Administration-Approved Treatments for Fibromyalgia: A Systematic Review and Network Meta-analysis. JAMA Netw Open. 2022 May 2. 5 (5):e2212939. [QxMD MEDLINE Link]. [Full Text].
Goldenberg D, Mayskiy M, Mossey C, Ruthazer R, Schmid C. A randomized, double-blind crossover trial of fluoxetine and amitriptyline in the treatment of fibromyalgia. Arthritis Rheum. 1996 Nov. 39 (11):1852-9. [QxMD MEDLINE Link].
Nelson LS, Erdman AR, Booze LL, Cobaugh DJ, Chyka PA, Woolf AD, et al. Selective serotonin reuptake inhibitor poisoning: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007 May. 45 (4):315-32. [QxMD MEDLINE Link].
Besson JM, Chaouch A. Peripheral and spinal mechanisms of nociception. Physiol Rev. 1987 Jan. 67 (1):67-186. [QxMD MEDLINE Link].
Colpaert FC, Tarayre JP, Koek W, Pauwels PJ, Bardin L, Xu XJ, et al. Large-amplitude 5-HT1A receptor activation: a new mechanism of profound, central analgesia. Neuropharmacology. 2002 Nov. 43 (6):945-58. [QxMD MEDLINE Link].
Arnold LM, Goldenberg DL, Stanford SB, et al. Gabapentin in the treatment of fibromyalgia: a randomized, double-blind, placebo-controlled, multicenter trial. Arthritis Rheum. 2007 Apr. 56(4):1336-44. [QxMD MEDLINE Link].
Crofford LJ, Rowbotham MC, Mease PJ, Russell IJ, Dworkin RH, Corbin AE, et al. Pregabalin for the treatment of fibromyalgia syndrome: results of a randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2005 Apr. 52(4):1264-73. [QxMD MEDLINE Link].
Crofford LJ, Mease PJ, Simpson SL, et al. Fibromyalgia relapse evaluation and efficacy for durability of meaningful relief (FREEDOM): a 6-month, double-blind, placebo-controlled trial with pregabalin. Pain. 2008 Jun. 136(3):419-31. [QxMD MEDLINE Link].
Mease PJ, Farmer MV, Palmer RH, Gendreau RM, Trugman JM, Wang Y. Milnacipran combined with pregabalin in fibromyalgia: a randomized, open-label study evaluating the safety and efficacy of adding milnacipran in patients with incomplete response to pregabalin. Ther Adv Musculoskelet Dis. 2013 Jun. 5 (3):113-26. [QxMD MEDLINE Link]. [Full Text].
Simpson DA. Gabapentin and venlafaxine for the treatment of painful diabetic neuropathy. J Clin Neuromuscul Dis. 2001 Dec. 3 (2):53-62. [QxMD MEDLINE Link].
Sadreddini S, Molaeefard M, Noshad H, et al. Efficacy of Raloxifen in treatment of fibromyalgia in menopausal women. Eur J Intern Med. 2008 Jul. 19(5):350-5. [QxMD MEDLINE Link].
Broughton RJ, Fleming JA, George CF, et al. Randomized, double-blind, placebo-controlled crossover trial of modafinil in the treatment of excessive daytime sleepiness in narcolepsy. Neurology. 1997 Aug. 49(2):444-51. [QxMD MEDLINE Link].
Schwartz TL, Rayancha S, Rashid A, et al. Modafinil treatment for fatigue associated with fibromyalgia. J Clin Rheumatol. 2007 Feb. 13(1):52. [QxMD MEDLINE Link].
Habib G, Artul S. Medical Cannabis for the Treatment of Fibromyalgia. J Clin Rheumatol. 2018 Aug. 24 (5):255-258. [QxMD MEDLINE Link].
Hershkovich O, Hayun Y, Oscar N, Shtein A, Lotan R. The role of cannabis in treatment-resistant fibromyalgia women. Pain Pract. 2023 Feb. 23 (2):180-184. [QxMD MEDLINE Link]. [Full Text].
Skrabek RQ, Galimova L, Ethans K, et al. Nabilone for the treatment of pain in fibromyalgia. J Pain. 2008 Feb. 9(2):164-73. [QxMD MEDLINE Link].
Walitt B, Klose P, Fitzcharles MA, Phillips T, Häuser W. Cannabinoids for fibromyalgia. Cochrane Database Syst Rev. 2016 Jul 18. 7 (7):CD011694. [QxMD MEDLINE Link]. [Full Text].
Rooks DS. Fibromyalgia treatment update. Curr Opin Rheumatol. 2007 Mar. 19(2):111-7. [QxMD MEDLINE Link].
Bootzin RR, Lahmeyer HW, Lilie JK. Easy Steps to Help You Sleep. Chicago, Ill: Searle Pharmaceuticals; 1994. 1-34.
Choy EH. Current treatments to counter sleep dysfunction as a pathogenic stimulus of fibromyalgia. Pain Manag. 2016 May. 6 (4):339-46. [QxMD MEDLINE Link].
Holman AJ, Myers RR. A randomized, double-blind, placebo-controlled trial of pramipexole, a dopamine agonist, in patients with fibromyalgia receiving concomitant medications. Arthritis Rheum. 2005 Aug. 52(8):2495-505. [QxMD MEDLINE Link].
Logan AC. Is there a fibromyalgia diet. Fibromyalgia Aware. Dec 2004-Mar 2005. 8:46-9.
Sanada K, Díez MA, Valero MS, Pérez-Yus MC, Demarzo MM, García-Toro M, et al. Effects of non-pharmacological interventions on inflammatory biomarker expression in patients with fibromyalgia: a systematic review. Arthritis Res Ther. 2015 Sep 26. 17:272. [QxMD MEDLINE Link]. [Full Text].
Ciappuccini R, Ansemant T, Maillefert JF, Tavernier C, Ornetti P. Aspartame-induced fibromyalgia, an unusual but curable cause of chronic pain. Clin Exp Rheumatol. 2010 Nov-Dec. 28 (6 Suppl 63):S131-3. [QxMD MEDLINE Link].
Smith JD, Terpening CM, Schmidt SO, Gums JG. Relief of fibromyalgia symptoms following discontinuation of dietary excitotoxins. Ann Pharmacother. 2001 Jun. 35 (6):702-6. [QxMD MEDLINE Link].
Cairns BE. Influence of pro-algesic foods on chronic pain conditions. Expert Rev Neurother. 2016. 16 (4):415-23. [QxMD MEDLINE Link].
Yang CC, Tsai ST, Ting B, Cheng YC, Wang CK, Chang JP, et al. Psychological Outcomes and Quality of Life of Fibromyalgia Patients with Vitamin D Supplementation-A Meta-Analysis. J Clin Med. 2023 Apr 6. 12 (7):[QxMD MEDLINE Link]. [Full Text].
Callahan LF, Freburger JK, Mielenz TJ, Wiley-Exley EK. Medical skepticism and the use of complementary and alternative health care providers by patients followed by rheumatologists. J Clin Rheumatol. 2008 Jun. 14(3):143-7. [QxMD MEDLINE Link].
[Guideline] Yokota S, Kikuchi M, Miyamae T. Juvenile fibromyalgia: Guidance for management. Pediatr Int. 2013 Aug. 55 (4):403-9. [QxMD MEDLINE Link].
[Guideline] Draheim N, Ebinger F, Schnöbel-Müller E, Wolf B, Häuser W. [Definition, diagnostics and therapy of chronic widespread pain and the (so-called) fibromyalgia syndrome in children and adolescents : Updated guidelines 2017]. Schmerz. 2017 Jun. 31 (3):296-307. [QxMD MEDLINE Link].
[Guideline] Sommer C, Alten R, Bär KJ, Bernateck M, Brückle W, Friedel E, et al. [Drug therapy of fibromyalgia syndrome : Updated guidelines 2017 and overview of systematic review articles]. Schmerz. 2017 Jun. 31 (3):274-284. [QxMD MEDLINE Link].
[Guideline] Schiltenwolf M, Eidmann U, Köllner V, Kühn T, Offenbächer M, Petzke F, et al. [Multimodal therapy of fibromyalgia syndrome : Updated guidelines 2017 and overview of systematic review articles]. Schmerz. 2017 Jun. 31 (3):285-288. [QxMD MEDLINE Link].
[Guideline] Fitzcharles MA, Ste-Marie PA, Goldenberg DL, Pereira JX, Abbey S, Choinière M, et al. Canadian Pain Society and Canadian Rheumatology Association recommendations for rational care of persons with fibromyalgia: a summary report. J Rheumatol. 2013 Aug. 40 (8):1388-93. [QxMD MEDLINE Link].
[Guideline] Petzke F, Brückle W, Eidmann U, Heldmann P, Köllner V, Kühn T, et al. [General treatment principles, coordination of care and patient education in fibromyalgia syndrome : Updated guidelines 2017 and overview of systematic review articles]. Schmerz. 2017 Jun. 31 (3):246-254. [QxMD MEDLINE Link].
[Guideline] Ablin JN, Amital H, Ahrenfeld M, et al. Guidelines for the diagnosis and treatment of the fibromyalgia syndrome (Hebrew). Harefuah. Available at http://www.ima.org.il/Ima/FormStorage/ Type7/clinical 68 fibrom.pdf. 2013; Accessed: September 14, 2021.
Arnold LM, Russell IJ, Diri EW, Duan WR, Young JP Jr, Sharma U, et al. A 14-week, randomized, double-blinded, placebo-controlled monotherapy trial of pregabalin in patients with fibromyalgia. J Pain. 2008 Sep. 9(9):792-805. [QxMD MEDLINE Link].

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.

of 4

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