Practice Essentials Fibromyalgia is a disorder of chronic, widespread pain and tenderness (see the image below). It typically presents in young or middle-aged women but can affect patients of either sex and at any age. Tender points in fibromyalgia. Signs and symptoms Fibromyalgia is a syndrome that consists of the following signs and symptoms : Persistent (≥3 mo) widespread pain (pain/tenderness on both sides of the body, above and below the waist, and includes the axial spine [usually the paraspinus, scapular, and trapezius muscles]) Stiffness Fatigue; disrupted and unrefreshing sleep Cognitive difficulties Multiple other unexplained symptoms, anxiety and/or depression, and functional impairment of activities of daily living (ADLs) Diagnosis Fibromyalgia is a diagnosis of exclusion and patients must be thoroughly evaluated for the presence of other disorders that could be the cause of symptoms before a diagnosis of fibromyalgia is made. The clinical assessment may reveal objective evidence for a discrete or comorbid illness, such as the following: Hypothyroidism Rheumatoid arthritis systemic lupus erythematosus Polymyalgia rheumatic Other inflammatory or autoimmune disorders Serious cardiac conditions in those with chest pain, dyspnea, and palpitations Laboratory testing Although patients with fibromyalgia do not have characteristic or consistent abnormalities on laboratory testing, routine laboratory and imaging studies can help to rule out diseases with similar manifestations and to assist in diagnosis of certain inflammatory diseases that frequently coexist with fibromyalgia. Such tests include the following: Complete blood count with differential Metabolic panel Urinalysis Thyroid-stimulating hormone level 25-hydroxy vitamin D level Vitamin B12 level Iron studies, including iron level, total iron binding capacity, percent saturation, and serum ferritin level Magnesium level Erythrocyte sedimentation rate Antipolymer antibody assay: May provide conclusive evidence for a subgroup of people with fibromyalgia; about 50% of fibromyalgia patients have antipolymer antibodies Patient self-report forms, clinical psychometric testing Self-report forms, for assessing patients’ pain, fatigue, and overall status, include the following: Modified Health Assessment Questionnaire Fibromyalgia Impact Questionnaire Checklist of current symptoms Scales for helplessness and cognitive performance The Physician Health Questionnaire - 9 for depression The Generalized Anxiety Disorder - 7 questionnaire for anxiety The Mood Disorder Questionnaire to screen for bipolar disease Psychometric testing provides a more comprehensive assessment and includes the following: Minnesota Multiphasic Personality Inventory Social Support Questionnaire Sickness Impact Profile Multidimensional Pain Inventory See Workup for more detail. Management There is no cure for fibromyalgia, but education, lifestyle changes, and proper medications can help the individual to regain control and achieve significant improvement. Models of pain behavior that interrelate biologic, cognitive, emotional, and behavioral variables form the basis for cognitive-behavioral and operant-behavioral approaches to adult pain management. Fibromyalgia in children responds to a combination of psychotherapy, exercise, relaxation techniques, and education. Pharmacotherapy is generally not indicated in children. Nonpharmacotherapy Diet (eg, promote good nutrition, vitamin supplementation, bone health, weight loss) Stress management Aerobic exercise (eg, low-impact aerobics, walking, water aerobics, stationary bicycle) Sleep therapy (eg, education/instruction on sleep hygiene) Psychologic/behavioral therapy (eg, cognitive-behavioral, operant-behavioral) Pharmacotherapy Always combine pharmacologic and nonpharmacologic therapy in the treatment of fibromyalgia. Aggressively treat comorbid depression. Medications used in the management of fibromyalgia include the following: Analgesics (eg, tramadol) Antianxiety agents (eg, alprazolam, clonazepam, zolpidem, zaleplon, Trazodone, buspirone, temazepam, sodium oxybate) Skeletal muscle relaxants (eg, cyclobenzaprine) Antidepressants (eg, amitriptyline, duloxetine, milnacipran, venlafaxine, desvenlafaxine) Anticonvulsants (eg, pregabalin, gabapentin, tiagabine) Alpha 2 agonists (eg, clonidine) Other agents used in fibromyalgia may include the following: Vitamins and minerals Malic acid and magnesium combination Antioxidants Amino acids Herbs and supplements If nonpharmacotherapy fails to improve sleep problems, the following medications may help: Antidepressants (eg, trazodone, SSRIs, SNRIs, tricyclic antidepressants) Anticonvulsants (eg, clonazepam, gabapentin, tiagabine) Nonbenzodiazepine hypnotics (eg, zolpidem, zaleplon, eszopiclone) Muscle relaxants (eg, cyclobenzaprine, tizanidine) Dopamine agonists (eg, pramipexole) Source
