Fibromyalgia – Interesting Facts, Symptoms, Diagnosis, Treatment, Prognosis

11 Interesting Facts of Fibromyalgia 

1. Fibromyalgia is a multisymptom syndrome characterized by chronic widespread pain, fatigue, and disruption of sleep
2. A patient satisfies the diagnosis of fibromyalgia by meeting criteria of the widespread pain index and symptom severity score in the context of consistent pain for at least 3 months ¹, without other explanation
3. Comorbidities of anxiety and depression may contribute to symptoms and findings of fibromyalgia, making assignment of historical and physical findings difficult to attribute to one disease or the other with confidence
4. Treatment embraces a combination of pharmacologic and nonpharmacologic treatment modalities including antidepressants, analgesics, sleep aids, cognitive therapy, patient education, and supportive adjuncts to improve mood, functionality, and physical tolerance
5. Complications from fibromyalgia (eg, narcotic abuse, central sensitization, cognitive dysfunction) take a significant toll on personal and public health resources
6. Most patients with fibromyalgia treated with a combination of pharmacologic and nonpharmacologic approaches report significant improvements in Revised Fibromyalgia Impact Questionnaire scores
7. Fibromyalgia (FM) is a chronic noninflammatory, nonautoimmune central afferent processing disorder leading to a diffuse pain syndrome as well as other symptoms.
8. Similar to patients with other chronic pain disorders, functional magnetic resonance imaging (fMRI) shows expanded receptive fields for central pain perception and emotional modulation in patients with FM.
9. The most effective drugs for FM syndrome (FMS) are tricyclic agents (TCAs), dual reuptake inhibitors, and anticonvulsants which downregulate sensory processing.
10. Opioids and corticosteroids are not effective in the treatment of FM and should be avoided.
11. Patient education, physical activity/exercise, and cognitive behavioral therapy (CBT) are important pillars of therapy alongside adjunctive medical therapy.

Pitfalls

• Patients with fibromyalgia tend to be sensitive to medication, and potential adverse effects of appropriate medications may be substantial; start with low doses and titrate upward slowly
• Although antidepressant medications are commonly used in the treatment of pain and disordered sleep, the doses are often suboptimal for treating depressive illness

• Fibromyalgia is a chronic pain syndrome that is considered a disorder of pain sensation ²
  • Characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, headaches, and cognitive and mood disturbances without any identifiable underlying medical or neurologic disorder
  • In some cases, physical examination will uncover point tenderness at predictable anatomic locations

What is fibromyalgia?

Fibromyalgia is a syndrome (a set of symptoms) that causes pain on both sides of your body, as well as the upper half and lower half of your body.

Areas called “tender points” may be especially painful when pressure is put on them. Common tender points are the back of the head, the elbows, the shoulders, the knees, the hip joints and around the neck.

Fibromyalgia affects about 6 million people in the United States. It is most common among people between 35 and 60 years of age. Women are more likely than men to have fibromyalgia. This syndrome might be hereditary (which means it runs in families). You may have family members with similar symptoms.

Classification

• Primary ¹
  • Not associated with any identifiable underlying condition
• Concomitant ¹
  • Associated with an underlying or concomitant condition that may have triggered the disordered pain sensation, but does not directly explain the patient’s symptoms

Fibromyalgia is real

Fibromyalgia is a condition that is often misunderstood. But your symptoms aren’t “all in your head.” Scientific research has shown that fibromyalgia is a real syndrome that causes real pain. Don’t let anyone discourage you from getting a diagnosis and treatment for your symptoms.

What are the symptoms of fibromyalgia?

Symptoms of fibromyalgia can include the following:

People who have fibromyalgia often also have one or more of the following:

• Increased sensitivity to pain
• A deep ache or a burning pain that gets worse because of activity, stress, weather changes or other factors
• Muscle stiffness or spasms
• Pain that moves around your body
• Feelings of numbness or tingling in your hands, arms or legs
• Feeling very tired or fatigued (out of energy), even when you get enough sleep
• Trouble sleeping
• Anxiety
• Depression
• Irritable bowel syndrome
• Restless legs syndrome
• Increased sensitivity to odors, bright lights, loud noises or medicines
• Headaches, migraines or jaw pain
• Dry eyes or mouth
• Dizziness and problems with balance
• Problems with memory or concentration (sometimes called the “fibro fog”)
• For women, painful menstrual periods

FM is a chronic (>3 months), noninflammatory, nonautoimmune central afferent processing disorder leading to a diffuse pain syndrome. The core symptoms typically include widespread pain, fatigue, stiffness, sleep disturbance, cognitive problems (fibrofog), and mood disorder (depression, anxiety, or both). Physical examination and pathologic investigation reveal no evidence of articular, osseous, or soft tissue inflammation or degeneration. Patients may have tender points on exam both above and below the waist; these tender points are neither sufficiently sensitive nor specific for FM; therefore, formal diagnosis is no longer reliant upon their presence. FM may occur alone (primary FM) or may be associated with a number of other disorders (secondary FM). In primary FM, laboratory results and radiographs are normal.

In 2010 new diagnostic criteria were proposed for FM. The purpose of these criteria was to recognize that FM was a condition of widespread pain and was frequently associated with other central pain sensitivity syndromes. The proposed criteria are:

• • Widespread pain index (WPI) ≥ 7 and a symptom severity (SS) scale score ≥ 5, or WPI = 3–6 and SS scale score ≥ 9
• • Symptoms present for at least 3 months
• • No other disorder to explain symptoms.

The WPI is the number of areas in which the patient has had pain over the last week. There are 19 areas (bilateral temporomandibular joint [TMJ, 2], shoulder [2], upper arm [2], lower arm [2], hip [2], upper leg [2], lower leg [2], neck [1], chest [1], abdomen [1], upper back [1], lower back [1]), therefore 19 is the maximum score. Tender points are no longer part of the criteria since patients (especially men) can have FM without characteristic tender points. The SS scale score is the sum of severity of four items over the past week. The four items are (1) fatigue, (2) waking from sleep unrefreshed, (3) cognitive disturbances, and (4) somatic symptoms. Each is subjectively scored for severity using a Likert score (0 = none, 1 = mild, 2 = moderate, and 3 = severe) so that the maximum score is 12.

Why do I feel depressed?

Depression or anxiety may occur as a result of your constant pain and fatigue, or the frustration you feel with the condition. It is also possible that the same chemical imbalances in the brain that cause mood changes also contribute to fibromyalgia.

Does fibromyalgia cause permanent damage?

No. Although fibromyalgia causes symptoms that can be very painful and uncomfortable, your muscles and organs are not being damaged. This condition is not life-threatening, but it is chronic (ongoing). Although there is no cure, there are many things you can do to feel better.

What are the Clinical Features of Fibromyalgia? 

History

• Patients generally have a long history of various regional (eg, neck, low back, shoulder, hip, extremities) musculoskeletal pain syndromes and ultimately develop widespread pain ³
• Many patients also experience symptoms or other syndromes thought to be caused by altered pain sensation ³
  • Tension headaches
  • Temporomandibular joint pain
  • Vulvodynia
  • Irritable bowel syndrome (eg, constipation, diarrhea, bloating, unexplained abdominal pain)
  • Painful bladder syndrome (eg, chronic pelvic pain, dysuria in the absence of infection)
  • Restless leg syndrome (eg, paresthesias, unexplained urge to move legs)
• Nonrestful sleep and fatigue are common ³
• Cognitive difficulties, anxiety, and depression are common ³
• Medical history may identify a potential triggering event (eg, traumatic injury, infection, inflammatory condition) ³
• The symptoms can be debilitating ⁴
• Family history may include chronic pain ³

Physical examination

• Examination is usually objectively unremarkable, but tenderness may be elicited at multiple points, including: ¹
  • Suboccipital muscle insertions
  • Anterior aspect of C6 vertebra
  • Midpoint of the upper border of the trapezius muscle
  • Origins of the supraspinatus muscles near the medial border of the scapula spine
  • Second rib costochondral junctions
  • Lateral epicondyles
  • Upper outer quadrants of buttocks in anterior fold of the muscle
  • Posterior to the greater trochanteric prominence
  • Knees at the medial fat pad proximal to the joint line
• Tenderness at tender points is not required to make a diagnosis of fibromyalgia
• Patients may exhibit generalized sensitivity to touch ¹

What Causes Fibromyalgia? 

• Central disorder of pain sensation

Risk factors and/or associations

Age

• Incidence decreases with age

Sex

• Women are affected more commonly than men, although reported ratios differ widely, depending upon diagnostic criteria ¹

Genetics

• Several genetic polymorphisms have been associated with fibromyalgia, but a causal relationship has not been established

How is Fibromyalgia diagnosed?

At your appointment, your doctor will ask about your personal and family medical histories. Be sure to tell your doctor whether any members of your immediate family have ever had similar symptoms or have been diagnosed with fibromyalgia. Your doctor will also need to know what medicines, vitamins or supplements you are taking.

He or she will ask about your symptoms and how long you have had them. It’s very important to give your doctor a clear, detailed description of your symptoms. Before going to your appointment, write down a complete list of the problems you’ve been having. Be sure to describe exactly what type of pain you have (for example, whether the pain is dull or sharp) and where you have been feeling pain. Tell your doctor whether your pain comes and goes, and what makes you feel better or worse.

If you have had any trouble sleeping or fatigue, tell your doctor how long you have had this problem. Your doctor may ask whether you have been feeling anxious or depressed since your symptoms began.

Your doctor will also perform a physical exam. This may include applying pressure to the tender points on your body. Your doctor may run tests (for example, blood tests) to be sure you don’t have one of the other conditions that have symptoms similar to fibromyalgia. Your doctor will also want to be sure that there isn’t anything else causing your pain.

Is it hard to diagnose fibromyalgia?

Unfortunately, it can take years for some people who have fibromyalgia to get a correct diagnosis. This can happen for many reasons. The main symptoms of fibromyalgia are pain and fatigue. These are also common symptoms of many other health problems, such as chronic fatigue syndrome, hypothyroidism and arthritis. Currently, there is no laboratory test or X-ray that can diagnose fibromyalgia.

It may take some time for your doctor to understand all of your symptoms and rule out other health problems so he or she can make an accurate diagnosis. As part of this process, your family doctor may consult with a rheumatologist (a doctor who specializes in pain in the joints and soft tissue).

Primary diagnostic tools

• Diagnosis is clinical and largely based on a set of self-reported criteria: the widespread pain index and the symptom severity score
• Patient satisfies the American College of Rheumatology diagnostic criteria for fibromyalgia if the following 3 conditions are met: ⁵
  • Symptoms have been present at a similar level for 3 months or longer ¹
  • A widespread pain index of 7 or higher and symptom severity score of 5 or higher or widespread pain index of 3 to 6 and symptom severity score of 9 or higher ¹
  • Patient does not have an underlying medical or neurologic disorder that would otherwise sufficiently explain the pain
• No diagnostic laboratory or imaging findings; studies are not indicated except to exclude other diagnoses
• Obtain CBC and levels of C‑reactive protein, calcium, creatine phosphokinase, TSH, and vitamin D initially to exclude metabolic or inflammatory cause of symptoms ⁶

Other diagnostic tools

• Widespread pain index (score range: 0-19 points) ¹
  • Consists of 19 specific anatomic locations; 1 point is assigned for each of those in which the patient has experienced pain within the preceding week
• Symptom severity score (score range: 0-12 points) ¹
  • Divided into 2 parts
    • Clinical criteria
      • Fatigue
        • None: 0 points
        • Mild: 1 point
        • Moderated: 2 points
        • Severe: 3 points
      • Waking unrefreshed
        • None: 0 points
        • Mild: 1 point
        • Moderate: 2 points
        • Severe: 3 points
      • Cognitive symptoms
        • None: 0 points
        • Mild: 1 point
        • Moderate: 2 points
        • Severe: 3 points
    • Symptoms
      • No symptoms: 0 points
      • 1 to 10 symptoms: 1 point
      • 11 to 24 symptoms: 2 points
      • 25 or more symptoms: 3 points

Differential Diagnosis

Most common

• Chronic fatigue syndrome
  • Presents as profound fatigue, lethargy, and diminished cognitive function
    • Unlike fibromyalgia, onset is often sudden and associated with viruslike symptoms (eg, fever, sore throat, cervical lymphadenopathy)
    • Symptoms become chronic and often disabling
  • There is often a significant component of musculoskeletal discomfort, and like fibromyalgia, many patients experience sleep disturbances, irritable bowels, temporomandibular joint pain, and other unexplained symptoms
  • Like fibromyalgia, chronic fatigue syndrome is a clinical diagnosis; the 2 conditions have significant clinical overlap, but pain is a more prominent feature of fibromyalgia, and fatigue is the overwhelming complaint in chronic fatigue syndrome
• Hypothyroidism
  • Disorder caused by inadequate synthesis and secretion of thyroid hormone
  • Presents as fatigue, diminished muscle strength, and physical weakness
  • Pain is generally absent, unlike fibromyalgia
  • Distinguished by hypotension, weight gain, dysesthesia, and intolerance of cool ambient temperature
  • Differentiated by diminished serum thyroid hormone levels ⁷
• Multiple sclerosis
  • Chronic disease characterized by multifocal areas of inflammation, demyelination, gliosis (scarring), and neuronal loss
  • Presents as fatigue, bladder urgency, and impaired vision and/or sensation
  • Like fibromyalgia, often follows a chronic stuttering course until diagnostic clinical picture emerges
    • Optic neuritis, if it occurs, is strongly suggestive of multiple sclerosis and is not a feature of fibromyalgia
  • Differentiated by elevated oligoclonal IgG level in cerebrospinal fluid ⁸
• Rheumatoid arthritis
  • Chronic autoimmune systemic inflammatory disease with articular and extra-articular manifestations
  • Presents as fatigue, diminished muscle strength, and physical weakness
  • Unlike fibromyalgia, pain is focused in joints, and there may be obvious swelling and decreased range of motion; small joints of the hand and fingers are most commonly involved
  • Differentiated by presence of rheumatoid factor on serum evaluation ⁹

How is Fibromyalgia treated?

• Pain relief ¹⁰
• Improvement of fatigue, sleep, functional status, mood, and symptom intensity scores (eg, Fibromyalgia Impact Questionnaire or Revised Fibromyalgia Impact Questionnaire scores) ¹⁰

Disposition

Recommendations for specialist referral

• Specialists in rheumatology, orthopedics, and neurology may be consulted for pain related to functional impairments (ie, pain sufficient to limit occupational capability) 
• Consider referral to psychologist and/or psychiatrist if there is a significant component of anxiety or depression

How is treated?

I’ve been diagnosed with fibromyalgia. What should I do now?

Fibromyalgia is a chronic condition. This means that it affects you over a long period of time – possibly your entire life. There will be times when your fibromyalgia may “flare up” and your symptoms will be worse. Other times you will feel much better. The good news is that your symptoms can be managed.

It’s important to have a health care team that understands fibromyalgia and has experience treating it. Your team will probably include your family doctor, a rheumatologist (a doctor who specializes in pain in the joints and soft tissue) and a physical therapist. Other health care professionals may help you manage other symptoms, such as mood or sleep problems. However, the most important member of your health care team is you. The more active you are in your care, the better you will feel.

How do I take an active role in my health care?

There isn’t currently a cure for fibromyalgia. Your care will focus on helping you minimize the impact of fibromyalgia on your life and treating your symptoms. Your doctor can prescribe medicine to help with your pain, but there are other things you will need to do to ease your symptoms. This is called “self-management.”

Self-management means that you take responsibility for doing what it takes to manage fibromyalgia effectively. It’s important for you to be responsible for your health. The treatment recommendations your doctor makes won’t do any good unless you follow them. He or she can’t make decisions for you or make you change your behavior. Only you can do these things.

In self-management, you and your health care team are partners in care. Your health care team can provide valuable advice and information to help you deal with fibromyalgia. However, there isn’t one treatment plan that works best for every person who has fibromyalgia. You’ll have to work with your care team to create a plan that’s right for you. After all, nobody knows more than you do about your feelings, your actions and how your fibromyalgia symptoms affect you.

How can self management help in fibromyalgia?

The following are some ways you can take an active role in managing your fibromyalgia symptoms:

Maintain a healthy outlook

Work with your health care team to choose realistic, short-term goals to manage your symptoms. Focus on what you can do today to feel better. Tell your doctor if you have been feeling depressed or anxious. These feelings are common among people who live with the pain and frustration of fibromyalgia. Your doctor may suggest cognitive behavioral therapy, which helps you replace negative thoughts with positive thoughts.

Find support

Don’t be afraid to ask for the help you need to deal with fibromyalgia. Support can come from your health care team, as well as friends and family members. For example, you could ask a friend to be your exercise buddy. There are also support groups specifically for people who have fibromyalgia.

Take medicines exactly as prescribed

Your doctor may prescribe medicines to reduce your pain, improve your mood and help you sleep better. Ask your doctor or pharmacist about each medicine and why you’re taking it. Be sure to take all medicines according to your doctor’s instructions.

Exercise

One of the best things you can do if you have fibromyalgia is engage in moderate exercise on a regular basis. Exercise can reduce your pain, give you more energy, reduce stress and help you sleep better. If you’re not used to exercising, be sure to talk to your doctor before you start. If you have a physical therapist on your health care team, he or she can help you develop an exercise routine that’s right for you. It’s usually best to start with low-impact aerobic exercise (for example, walking or water aerobics) for a short period of time a few days a week. As your pain decreases and your energy increases, you can gradually increase the intensity and frequency of your exercise.

Recognize stress and take steps to reduce it

Because stress makes the symptoms of fibromyalgia worse, it’s important to recognize when you’re feeling stressed. Signs of stress may include a feeling of tension in your shoulders or neck, an upset stomach or a headache. Unfortunately, there isn’t a way to completely get rid of stress in your life. However, you can focus on changing the way you react to stress. For example, you might set aside time each day to practice deep-breathing techniques or meditation.

Establish healthy sleep habits

Lack of sleep can make your fibromyalgia symptoms worse. And increased pain makes it hard to get restful sleep. To avoid getting caught in this cycle, try to have healthy sleeping habits. Avoid caffeine and alcohol before bedtime, go to bed and wake up at the same time each day (including weekends), and limit naps during the day.

Get into a routine

Many people who have fibromyalgia do better when their schedule follows a routine pattern. This usually means that each day they have meals at the same times, go to bed and get up at the same times, and exercise at the same time. Try to keep your weekend and holiday schedules as similar to your weekday schedule as possible.

Make healthy lifestyle choices

By making healthy choices, you’ll have more energy, you’ll feel better and you’ll lower your risk for other health problems. Eat a healthy, balanced diet. Limit the amount of alcohol you drink. If you use tobacco products, stop. Lose weight if you are overweight.

What medicines might my doctor recommend to help my symptoms?

Several medicines can help reduce the symptoms of fibromyalgia. Many of these medicines are taken before bedtime and help reduce pain and improve sleep.

Your doctor may recommend treating your symptoms with acetaminophen (one brand: Tylenol) first. He or she may also recommend an anti-depressant, such as duloxetine or milnacipran. Anti-seizure medicines, such as preglabin, may also be effective in managing your pain. Nonsteroidal anti-inflammatory medicines (which include ibuprofen, aspirin and naproxen) are not usually effective in treating fibromyalgia when taken alone.

Questions to Ask Your Doctor

• How do you know that fibromyalgia is causing my symptoms?
• What could have caused my fibromyalgia?
• Will I need to take medicines? Will they interact with other medicines I take?
• Will alternative therapies (massage, acupuncture, yoga, etc.) help relieve my symptoms?
• What should I do if my symptoms don’t respond to treatment or get worse?
• How do I talk to people about my condition? How do I explain that my pain is real?
• Are there any local support groups for people who have fibromyalgia?

An Important Note about Your Care

You will need to follow your doctor’s recommendations carefully. Making changes in your lifestyle and daily habits can help you feel better. Remember, your treatment won’t be as effective if you don’t take an active role in your health care.

Treatment is largely symptomatic and supportive

Optimal treatment requires a multidisciplinary approach; effective elements include patient education, cognitive behavioral therapy, aerobic exercise, and medication (when needed) 

Nonpharmacologic therapy is first line therapy and shows positive effects 

Most effective drugs for pain management are antidepressants and anticonvulsants, but effects tend to be small 

Cyclobenzaprine, low-dose amitriptyline, or pregabalin at bedtime may improve quality of sleep 

When used as monotherapy, NSAIDs have not been found to be more effective than placebo 

Use of tramadol is controversial, but may be appropriate in patients whose symptoms are disabling despite use of other medications and nonpharmacologic modalities; other opioids are not recommended 

Fibromyalgia patients may be unusually sensitive to medication; experts recommend starting at the lowest dose and escalating slowly 

Drug therapy

• Antidepressants
  • Tricyclic antidepressants
    • Amitriptyline
      • Amitriptyline Hydrochloride Oral tablet; Adults: In one trial, amitriptyline 10 mg PO at bedtime and titrated up to 50 mg PO at bedtime was superior to placebo at 1 month but not significantly better at 3 or 6 months.
    • Cyclobenzaprine
      • Cyclobenzaprine reduces pain and improves quality of sleep; effects on fatigue are inconsistent 
      • Cyclobenzaprine Hydrochloride Oral tablet; Adults: Use not established; not FDA-approved. Low-dose cyclobenzaprine has been studied. Doses range from 1 mg to 4 mg PO once nightly. Treatment may improve sleep and pain scores. Low-dose side effects include sedation and dry mouth.
  • Serotonin and norepinephrine reuptake inhibitors
    • Duloxetine and milnacipran have some efficacy in reducing pain but not fatigue or sleep disturbance 
    • Duloxetine
      • Duloxetine Oral capsule, gastro-resistant pellets; Adults: Initially, 30 mg PO once daily for 1 week. Then, increase to recommended dose of 60 mg PO once daily. Some patients may respond to 30 mg/day. Max: 60 mg/day.
    • Milnacipran
      • Milnacipran Hydrochloride Oral tablet; Adults: The usual dose is 50 mg PO twice daily after titration. Titration schedule: 12.5 mg PO as a single dose on day 1, then 12.5 mg PO twice daily (days 2 and 3), then 25 mg PO twice daily (days 4 to 7). Give 50 mg PO twice daily thereafter. May give 100 mg PO twice daily if needed and tolerated. Max: 200 mg/day PO. DISCONTINUATION: If necessary after extended use, withdraw therapy gradually to minimize the potential for adverse effects.
• Anticonvulsants
  • May reduce pain significantly in some patients and has some benefit in relieving other symptoms (eg, sleep improvement) 
  • Pregabalin
    • Pregabalin Oral capsule; Adults: 75 mg PO twice daily, initially. May increase dose to 150 mg PO twice daily after 1 week based on efficacy and tolerability. May further increase the dose to 225 mg PO twice daily for patients who do not experience sufficient benefit on 300 mg/day.
  • Gabapentin is used by some as an alternative 
• Analgesics 
  • Tramadol
    • For standard-onset analgesia
      • Tramadol Hydrochloride Oral tablet; Adults 18 to 75 years: 25 mg PO once daily, initially. Titrate by 25 mg/day as separate doses every 3 days to 100 mg/day (25 mg 4 times daily). May further increase by 50 mg/day every 3 days to 200 mg/day (50 mg 4 times daily). Usual dose: 50 to 100 mg every 4 to 6 hours as needed. Max: 400 mg/day.
      • Tramadol Hydrochloride Oral tablet; Adults 76 years and older: 25 mg PO once daily, initially. Titrate by 25 mg/day as separate doses every 3 days to 100 mg/day (25 mg 4 times daily). May further increase by 50 mg/day every 3 days to 200 mg/day (50 mg 4 times daily). Usual dose: 50 to 100 mg every 4 to 6 hours as needed. Max: 300 mg/day.
    • For rapid-onset analgesia
      • Tramadol Hydrochloride Oral tablet; Adults: 50 to 100 mg PO every 4 to 6 hours as needed. Max: 400 mg/day.
      • Tramadol Hydrochloride Oral tablet; Adults 76 years and older: 50 to 100 mg PO every 4 to 6 hours as needed. Max: 300 mg/day.

Nondrug and supportive care 

• Educate patients about fibromyalgia, treatment options, pain management, and self-management programs
• Cognitive behavioral therapy has produced both short-term (6 months) and long-term (30 months) benefits, and is recommended as a component of treatment
  • May include relaxation training, reassessment of priorities, and goal setting
• Regular graded exercise may improve symptoms of fibromyalgia and is recommended for that purpose, as well as for general health maintenance in patients with fibromyalgia 
  • Aerobic and strength exercises both have beneficial effects on pain, physical function, and well-being and lack the safety concerns of medications 
  • Aerobic exercise programs, either land or water based, have been effective in reducing pain and fatigue 
  • Although the optimal exercise program has not been defined in terms of type or intensity, a 30-minute session of the patient’s choice, 2 to 3 times per week, has been recommended 
• Other nonpharmacologic therapies that have shown some benefit include acupuncture, hydrotherapy, mindfulness, and meditative movement; small studies have reported medical cannabis to be effective 

Comorbidities

• Anxiety
  • Consequences of pain, fatigue, and cognitive dysfunction negatively influence the sustained performance of physical and mental tasks
• Depression
  • Although antidepressant medications are commonly used in the treatment of pain and disordered sleep, the doses are often suboptimal for treating depressive illness

Special populations

• The safety of FDA-approved drugs for fibromyalgia (duloxetine, pregabalin and milnacipran) have not been studied in pregnancy, and are classified as category C; administer only when the benefit exceeds possible risk

Monitoring

• Determine frequency of follow-up by the activity of the condition; more frequent follow-up is necessary after diagnosis until symptoms have stabilized and after symptom flares 
• Objective measures, such as the Revised Fibromyalgia Impact Questionnaire and Beck Depression Inventory instrument may be used, but are not universally recommended 
  • Fibromyalgia Impact Questionnaire grades the degree of difficulty over the previous 7 days in 9 routine activities, the patient’s overall impression of functionality, and the intensity of 10 specific symptoms, for a maximum score of 100 

Complications

• Most complications are related to adverse effects of medication, including narcotic addiction
• Chronic pain may exacerbate existing anxiety and depression

Prognosis

• Most patients with fibromyalgia treated with a combination of pharmacologic and nonpharmacologic approaches report significant improvements in Revised Fibromyalgia Impact Questionnaire scores
• Fibromyalgia is a chronic condition, characterized by frequent health care use and periods of relative stability punctuated by symptom flares 

REFERENCES

1: Jay GW et al: Fibromyalgia. Dis Mon. 61(3):66-111, 2015