Fibromyalgia

Current evidence suggests fibromyalgia may be a centrally mediated disorder of pain sensitivity. The cause is unknown, but disruption of stage 4 sleep may contribute, as can emotional stress. Fibromyalgia may be precipitated by a viral or other systemic infection (eg, Lyme disease Lyme Disease Lyme disease is a tick-transmitted infection caused by the spirochete Borrelia species. Early symptoms include an erythema migrans rash, which may be followed weeks to months later by... read more or perhaps COVID-19 infection COVID-19 COVID-19 is a respiratory illness caused by the novel coronavirus SARS-CoV-2. Infection may be asymptomatic or have symptoms ranging from mild upper respiratory symptoms to acute respiratory... read more [ 1 Etiology reference Fibromyalgia is a common, incompletely understood nonarticular, noninflammatory disorder characterized by generalized aching (sometimes severe); widespread tenderness of muscles, areas around... read more ]) or a traumatic event, but additional or prolonged antiviral or antibiotic therapy is not indicated because it is not effective.

Stiffness and pain frequently begin gradually and diffusely and have an achy quality. Pain is widespread and may worsen with fatigue, muscle strain, or overuse.

Patients typically have a variety of somatic symptoms. Fatigue is common, as are cognitive disturbances such as difficulty concentrating and a general feeling of mental cloudiness. Many patients also have symptoms of irritable bowel syndrome Symptoms and Signs Irritable bowel syndrome is characterized by recurrent abdominal discomfort or pain with at least two of the following characteristics: relation to defecation, association with a change in frequency... read more , interstitial cystitis Symptoms and Signs Interstitial cystitis is noninfectious bladder inflammation that causes pain (suprapubic, pelvic, and abdominal), urinary frequency, and urgency with incontinence. Diagnosis is by history and... read more , or migraine Symptoms and Signs Migraine is an episodic primary headache disorder. Symptoms typically last 4 to 72 hours and may be severe. Pain is often unilateral, throbbing, worse with exertion, and accompanied by symptoms... read more or tension headaches Symptoms and Signs Tension-type headache causes mild generalized pain (usually viselike) without the incapacity, nausea, or photophobia associated with migraine. (See also Approach to the Patient With Headache... read more . Paresthesias may be present, typically bilaterally and often migratory.

Symptoms can be exacerbated by environmental or emotional stress, poor sleep, trauma, exposure to dampness or cold, or by a physician, family member, or friend who implies that the disorder is “all in the head.”

Patients may be stressed, tense, anxious, fatigued, ambitious, and sometimes depressed. Patients are not uncommonly high-achieving perfectionists.

Physical examination is unremarkable except that specific, discrete areas of muscle (tender points) often are tender when palpated. The tender areas are not swollen, red, or warm; such findings should suggest an alternative diagnosis.

Fibromyalgia is suspected in patients with the following:

The diagnosis of fibromyalgia should be considered in people who have had widespread pain for at least 3 months, particularly when accompanied by various somatic symptoms. Pain is considered widespread when patients have pain in the left and right side of the body, above and below the waist, and in the axial skeleton (cervical spine, anterior chest or thoracic spine, or low back).

The diagnosis is based on clinical criteria from the American College of Rheumatology (1 Diagnosis reference Fibromyalgia is a common, incompletely understood nonarticular, noninflammatory disorder characterized by generalized aching (sometimes severe); widespread tenderness of muscles, areas around... read more ), which include a combination of joint and usually non-joint pain (sometimes including widespread body-wide pain) and the presence of various other cognitive and somatic symptoms, such as those listed above, which are graded in severity. Previous criteria relied on the presence of tenderness at some of 18 specified tender points. This criterion was eliminated because nonspecialists sometimes have difficulty evaluating tenderness consistently, the tender points may fluctuate in intensity, and it was thought advantageous to have criteria that are entirely symptom-based. However, tenderness is quite common, and some specialists continue to assess it systematically.

Tests for other causes of patient symptoms should include erythrocyte sedimentation rate (ESR) or C-reactive protein, creatine kinase (CK), and probably tests for hypothyroidism Diagnosis Hypothyroidism is thyroid hormone deficiency. Symptoms include cold intolerance, fatigue, and weight gain. Signs may include a typical facial appearance, hoarse slow speech, and dry skin. Diagnosis... read more and hepatitis C Diagnosis Hepatitis C is caused by an RNA virus that is often parenterally transmitted. It sometimes causes typical symptoms of viral hepatitis, including anorexia, malaise, and jaundice but may be asymptomatic... read more (which can cause fatigue and generalized myalgias). Fibromyalgia does not typically cause abnormalities in these tests. Other tests (eg, serologic testing for rheumatic disorders) should be done only if indicated by findings on history and/or physical examination.

To avoid potential pitfalls, clinicians should consider the following:

Fibromyalgia tends to be chronic but may remit spontaneously if stress decreases. It can also recur at frequent intervals. Functional prognosis is usually favorable for patients being treated with a comprehensive, supportive program, but symptoms tend to persist to some degree. Prognosis may be worse if there is a superimposed mood disorder that is not addressed.

Stretching exercises, aerobic exercises, sufficient sound sleep, local applications of heat, and gentle massage may provide relief. Overall stress management (eg, deep breathing exercises, meditation, psychologic support, counseling if necessary) is important.

Exercises to gently stretch the affected muscles should be done daily; stretches should be held for about 30 seconds and repeated about 5 times. Aerobic exercise (eg, fast walking, swimming, exercise bicycling) can lessen symptoms.

Improving sleep is critical. Sedating drugs can be taken but only at night and only to improve sleep. Low-dose oral tricyclic antidepressants at bedtime (eg, amitriptyline 10 to 50 mg, trazodone 50 to 150 mg, doxepin 10 to 25 mg) or the pharmacologically similar cyclobenzaprine 10 to 30 mg may promote deeper sleep and decrease muscle pain. The lowest effective dose should be used. Drowsiness, dry mouth, and other adverse effects may make some or all of these drugs intolerable, particularly for older patients.

Nonopioid analgesics (eg, acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]) may help some patients. Opioids should be avoided. Pregabalin, duloxetine, and milnacipran are available for treatment of fibromyalgia, but should be used as adjuncts to exercise, measures to improve sleep, and stress management; they may help modestly to reduce pain.

Occasional injections of 0.5% bupivacaine or 1% lidocaine 1 to 5 mL are used to treat incapacitating areas of focal tenderness, but such injections should not be relied on as primary treatment because evidence does not support their regular use.

Drugs taken by the patient should be reviewed to identify those that may aggravate sleep problems. Such drugs should be avoided. Anxiety Overview of Anxiety Disorders Anxiety disorders are characterized by persistent and excessive fear and anxiety and the dysfunctional behavioral changes a patient may use to mitigate these feelings. Anxiety disorders are... read more , depression Depressive Disorders Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more , and especially bipolar disorder Bipolar Disorders Bipolar disorders are characterized by alternating episodes of mania and depression, although many patients have a predominance of one or the other. Exact cause is unknown, but heredity, changes... read more , if present, should be addressed.

Evidence also supports use of capsaicin, biofeedback Biofeedback For biofeedback, a type of mind-body medicine, electronic devices are used to provide information to patients about biologic functions (eg, heart rate, blood pressure, muscle activity, skin... read more , massage Massage Therapy In massage therapy (a manipulative and body-based practice), body tissues are manipulated to reduce pain, relieve muscle tension, and reduce stress. The therapeutic value of massage for many... read more , hypnotherapy Hypnotherapy Hypnotherapy, a type of mind-body medicine, is derived from western psychotherapeutic practice. Patients are put into an advanced state of relaxation and focused concentration to help them improve... read more , chiropractic interventions Chiropractic In chiropractic (a manipulative and body-based practice), the relationship between the structure of the spine and other articulating surfaces and their interaction with the nervous system is... read more , and other complementary and alternative therapies that are a part of the European Alliance of Associations for Rheumatology (EULAR) recommendations for management of fibromyalgia (1 Treatment reference Fibromyalgia is a common, incompletely understood nonarticular, noninflammatory disorder characterized by generalized aching (sometimes severe); widespread tenderness of muscles, areas around... read more ). Although randomized trials and systematic reviews have evaluated some of these therapies against controls, evidence for effects are not robust overall.