Fibromyalgia: The Best Treatment Options

Unfortunately, scientists still don't know exactly what causes fibromyalgia. However, they do know a few key risk factors commonly associated with the onset of fibromyalgia.

• Family History: Those who have immediate family members diagnosed with fibromyalgia have a higher chance of developing it themselves (3, 4).‍
• Traumatic Injury: Examples of traumatic events which can result in significant injury include falls, car accidents, surgeries, and job-related injuries (5).‍
• Psychological Stressors: Events such as divorces, deaths in the family, or stressful working conditions can contribute to fibromyalgia onset (5).‍
• Other Chronic Pain Conditions: People with other conditions such as rheumatoid arthritis, osteoarthritis, and lupus are more likely to develop fibromyalgia (4)

Additionally, research indicates that the central nervous system (the brain and spinal cord) processes pain differently in people with fibromyalgia (6). Chemical changes in the brain result in a heightened response to both painful and non-painful sensations, leading to the development of chronic widespread pain (3, 6).

The current diagnostic criteria established by the American College of Rheumatology (ACR) include the following (3, 4):

• Pain duration of at least 3 months
• Dispersion and number of painful areas (assessed with a body pain chart)
• The severity of fatigue, sleeplessness, and cognitive difficulties (assessed with a symptom questionnaire)
• Lack of another medical condition which can explain the pain

Your doctor will likely choose to perform a series of blood tests in order to rule out any other potential cause of pain.

There is no cure for fibromyalgia at this time. However, several interventions are available for treating symptoms associated with the condition.

A typical treatment course for fibromyalgia involves a combination of both pharmacological (drug-based) and non-pharmacological interventions (7, 8).‍

Drug-Based Treatments

Several types of drugs may be integrated into the treatment plan to address different symptoms.

Often, people struggling with fibromyalgia pain will try using over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen for pain relief. They may also try other over-the-counter pain relievers such as acetaminophen (Tylenol). However, several studies indicate these drugs aren't helpful in reducing fibromyalgia pain and aren't recommended (4, 7).

Instead, doctors typically recommend one of the following types of drugs:

• Anticonvulsants/Antiepileptics: These drugs help relieve pain. They may also help with improving sleep and fatigue. Examples of antiepileptic drugs include pregabalin (Lyrica) and gabapentin (Neurontin). Current research supports the use of pregabalin for fibromyalgia pain more so than gabapentin (7, 9, 10).
• Antidepressants: These drugs help relieve pain and fatigue, as well as helping with depression or anxiety. Moderate quality evidence supports the use of low-dose amitriptyline (Elavil), a tricyclic antidepressant, for fibromyalgia (7). Even stronger evidence supports the effectiveness of serotonin reuptake inhibitors (SNRIs). These constitute a specific class of antidepressants that modifies neurotransmitter levels in the central nervous system to alter mood and pain. The SNRIs with the strongest research evidence are duloxetine (Cymbalta) and milnacipran (Savella) (7, 8, 10).
• Muscle relaxants: These drugs help improve sleep. They may also help reduce pain. Preliminary evidence supports the use of cyclobenzaprine (Flexeril) as a sleeping aid for fibromyalgia (7).
  

Of these drugs, the U.S. Food and Drug Administration (FDA) has approved the use of pregabalin, duloxetine, and milnacipran specifically for management of fibromyalgia (4).

Though drug-based interventions are moderately effective in managing fibromyalgia symptoms, they don’t produce long-lasting benefits beyond the course of medication use. They also carry a variety of side effects which can impact your ability to tolerate them. Possible side effects include (4):

• Dizziness
• Nausea
• Drowsiness
• Excessive sweating
• Constipation
• Dry mouth
• Increased heart rate
• Weight gain
• Blurred vision
  

Because of these potential side effects and the limited long-term benefits, some guidelines encourage non-pharmacological interventions first before initiating any courses of medication (7, 10, 11, 12).‍

Exercise

Of all treatment options available for fibromyalgia, the one with the highest success rate in reducing both pain and disability is exercise (4, 7). Studies show that exercise stimulates brain regions involved in pain inhibition, reducing overall pain levels (6). Physical activity and exercise also have positive impacts on sleep and cognitive function (12).

Types of exercise effective for fibromyalgia include:

• Aerobic exercise: This type of exercise provides the greatest benefit in cases of fibromyalgia (4, 7). Recommendations include starting with low to moderate intensity activities like walking or swimming for short durations, then progressing gradually to 30 - 60 minutes of the activity. You should engage in aerobic activity 2 - 3 times a week consistently for maximum benefit (4, 12, 13).

• Strengthening exercise: This type of exercise maintains muscular strength and reduces physical fatigue (14). You can perform these exercises with free weights, elastic resistance bands, weight machines, or your own body weight.

• Flexibility/stretching exercises: This type of exercise improves joint range of motion and reduces muscle stiffness. On its own, it’s helpful in reducing pain. However, combining it with aerobic and strength training amplifies the benefits (12, 13).

Unlike the medications often used in fibromyalgia treatment, exercise has minimal side effects. Increased pain or fatigue may occur immediately after exercise if the session was excessively intense. Otherwise, no adverse events have been associated with physical exercise (4).

If you’re concerned about initiating an exercise program safely without inadvertently causing any pain flare-ups, consult your physical therapist. They’ll establish an exercise program combining aerobic, strengthening, and flexibility activities tailored specifically for you to minimize any risk of flare-ups.‍

Cognitive Behavioral Therapy (CBT)

CBT seeks to address emotional distress and exaggerated pain-focused behavior experienced in response to chronic pain. By integrating specific, structured techniques to alter negative thought processes, CBT alters your response to pain, which in turn helps to relieve pain (4, 12, 15).

In addition, CBT reduces anxiety and depression associated with fibromyalgia and provides coping strategies for limiting the impact of fibromyalgia on daily life. Several studies and published treatment guidelines recommend the use of CBT in conjunction with exercise to treat fibromyalgia pain and the related psychological effects (4, 10, 15).

Although CBT is commonly recommended for fibromyalgia, it does come with some disadvantages. It can be expensive, and mental health providers offering CBT for chronic pain conditions may be difficult to find. However, Internet-based programs allow more accessibility to the treatment. Evidence also shows that positive, long-term outcomes can occur with as few as 2 - 4 sessions, which limits the associated cost (4, 15).‍

Sleep Hygiene

Establishing a steady sleep routine can minimize the fatigue and cognitive difficulties associated with fibromyalgia. It can also have a positive impact on pain (4). Examples of healthy sleep habits include:

• Avoiding caffeine and TV immediately before bed
• Consistent sleep schedule on weekdays and weekends
• No napping during the day
• Use of blackout curtains to block light during sleeping hours‍

Patient Education

Proper education on the diagnosis and prognosis of fibromyalgia is critical to any treatment plan, regardless of what other interventions are included. Education allows for realistic expectations and improves adherence to other parts of the treatment plan (3, 4).

Since no particular intervention completely resolves fibromyalgia symptoms on its own, fibromyalgia patients often seek additional treatments to complement the standard treatments in the hopes of further reducing their symptoms.

While these other interventions haven’t yet been as extensively researched as more traditional treatment approaches, several preliminary studies show encouraging results.‍

Acupuncture

Initial studies indicate that when combined with standard treatments, acupuncture decreases pain by up to 30% while also reducing fatigue (7). However, additional research is needed to better understand the relative efficacy of acupuncture over placebo (sham) treatments (1, 16).‍

Yoga and Tai Chi

These movement-based interventions have gained some strong recommendations for reducing pain and improving sleep in just the last few years (7, 10, 16). Some countries classify them as exercise interventions because of their emphasis on movement and support their use as part of the non-pharmacological component of treatment (10). In my own clinical practice working with clients who have fibromyalgia, several clients have found either yoga or Tai Chi helpful in managing their pain. They also report enjoying yoga and Tai Chi, which motivates them to continue participating.‍

Meditation/Mindfulness Therapy

Most studies assessing meditation indicate positive, short-term effects on pain, anxiety, depression, and psychological distress (7, 16, 17). More clinical trials need to be conducted to determine if these effects translate into long-term benefits.

Dietary changes

A variety of dietary changes have been proposed for optimizing treatment outcomes in cases of fibromyalgia. Suggested diets include:

• Gluten-free (18)
• Additive-free (no MSG or aspartame) (18)
• Low fermentable oligo-, di-, and monosaccharides, alcohols, and polyols (FODMAPs) (18)
• Hypocaloric (low calorie) diet (18)
• Raw vegetarian diet (18)
• Increased intake of specific vitamins and minerals, such as vitamins B and D (19)
  

Of these proposed diets, the low FODMAPs diet demonstrates the most encouraging results in terms of pain relief, quality of life improvement, and weight loss (18). More clinical trials need to occur on each of these proposed diets to further substantiate efficacy.

Medical Cannabis

In recent years, medical cannabis has gained more attention as an alternative for managing chronic pain syndromes. While its use is still controversial, preliminary studies from the last 2 - 3 years show promising results for pain relief and quality of life in people with fibromyalgia syndrome (20, 21).

Other complementary and alternative treatments include chiropractic care, homeopathy, hypnosis, guided imagery, massage therapy, and biofeedback. Each of these has demonstrated less promising research results, and receive fewer recommendations in global fibromyalgia treatment guidelines (7, 10, 16).

Though a cure for fibromyalgia doesn’t yet exist, there are many effective treatments for managing the symptoms.The best approaches incorporate a mix of different treatment methods, with emphasis on non-pharmacological treatments and lifestyle changes for long-term relief.

To determine the best combination of treatments for your particular case of fibromyalgia, write down all your symptoms and questions prior to seeing your doctor. Be sure to also make note of any particular treatment options you favor, so you and your doctor can discuss the pros and cons. With good preparation and an open mind, you'll be able to craft the right treatment plan with your healthcare provider.