In fibromyalgia, any fibromuscular tissues may be involved, especially those of the occiput, neck, shoulders, thorax, low back, and thighs. There is no specific histologic abnormality. Symptoms and signs of fibromyalgia are generalized, in contrast to localized soft-tissue pain and tenderness (myofascial pain syndrome Myofascial Pain Syndrome Myofascial pain syndrome (previously known as myofascial pain and dysfunction syndrome [MPDS or MFPDS]) can occur in patients with a normal temporomandibular joint. It is caused by muscle tension... read more ), which is often related to overuse or microtrauma.
Fibromyalgia is common; it is about 7 times more common among women, usually young or middle-aged women, but can occur in men, children, and adolescents. Because of the sex difference, it is sometimes overlooked in men. It often occurs in patients with other concomitant, unrelated systemic rheumatic disorders, thus complicating diagnosis and management.
Etiology of 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 an acute, sometimes severe, respiratory illness caused by the novel coronavirus SARS-CoV-2. Prevention is by vaccination and infection control precautions (eg, face masks, handwashing... 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.
1. Ursini F, Ciaffi J, Mancarella L, et al: Fibromyalgia: a new facet of the post-COVID-19 syndrome spectrum? Results from a web-based survey. RMD Open. 7(3):e001735, 2021. doi: 10.1136/rmdopen-2021-001735. PMID: 34426540; PMCID: PMC8384499.
Symptoms and Signs of Fibromyalgia
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.
Diagnosis of Fibromyalgia
Usually testing and a detailed physical examination to exclude other disorders
Fibromyalgia is suspected in patients with the following:
Generalized pain and tenderness, especially if disproportionate to physical findings
Negative laboratory results despite widespread symptoms
Fatigue as a predominant symptom
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 is often overlooked in men, children, and adolescents.
Chronic fatigue syndrome Chronic Fatigue Syndrome Chronic fatigue syndrome (CFS, also called myalgic encephalomyelitis/chronic fatigue syndrome [ME/CFS]) is a syndrome of life-altering fatigue lasting > 6 months that is unexplained and is accompanied... read more (systemic exertion intolerance disease) can cause similar generalized myalgias and fatigue, and laboratory test results are typically normal.
Polymyalgia rheumatica Polymyalgia Rheumatica Polymyalgia rheumatica is a syndrome closely associated with giant cell arteritis (temporal arteritis). It affects adults > 55. It typically causes severe pain and stiffness in proximal muscles... read more causes more focused myalgias, particularly in older adults; it can be distinguished from fibromyalgia because it tends to affect proximal muscles selectively, is more symptomatic in the morning, and is usually accompanied by high ESR and C-reactive protein levels.
In patients with systemic rheumatic disorders, diagnosing coexistent fibromyalgia may be more difficult, but it is quite common. For example, fibromyalgia may be misinterpreted as an exacerbation of rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis is a chronic systemic autoimmune disease that primarily involves the joints. Rheumatoid arthritis causes damage mediated by cytokines, chemokines, and metalloproteases.... read more or systemic lupus erythematosus Systemic Lupus Erythematosus (SLE) Systemic lupus erythematosus is a chronic, multisystem, inflammatory disorder of autoimmune etiology, occurring predominantly in young women. Common manifestations may include arthralgias and... read more .
Pearls & Pitfalls
Prognosis for Fibromyalgia
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.
Treatment of Fibromyalgia
Stretching and aerobic exercise, local heat, and massage
Tricyclic antidepressants or cyclobenzaprine to improve sleep
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 episodes of mania and depression, which may alternate, although many patients have a predominance of one or the other. Exact cause is unknown, but heredity... 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.
1. Macfarlane GJ, Kronisch C, Dean LE, et al: EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis. 76(2):318-328, 2017. doi: 10.1136/annrheumdis-2016-209724. Epub 2016 Jul 4. PMID: 27377815.
Fibromyalgia-related stiffness and pain 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.”
Suspect fibromyalgia when generalized pain and tenderness and fatigue are unexplained, have lasted years, or are out of proportion to physical and laboratory findings.
Consider checking erythrocyte sedimentation rate (ESR) or C-reactive protein, creatine kinase (CK), and 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 , and consider chronic fatigue syndrome Chronic Fatigue Syndrome Chronic fatigue syndrome (CFS, also called myalgic encephalomyelitis/chronic fatigue syndrome [ME/CFS]) is a syndrome of life-altering fatigue lasting > 6 months that is unexplained and is accompanied... read more and polymyalgia rheumatica Polymyalgia Rheumatica Polymyalgia rheumatica is a syndrome closely associated with giant cell arteritis (temporal arteritis). It affects adults > 55. It typically causes severe pain and stiffness in proximal muscles... read more . Do further testing for other rheumatologic diseases only if they are specifically suggested by clinical evaluation.
Consider fibromyalgia in patients having apparent painful exacerbations of systemic rheumatic disorders such as rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis is a chronic systemic autoimmune disease that primarily involves the joints. Rheumatoid arthritis causes damage mediated by cytokines, chemokines, and metalloproteases.... read more or systemic lupus erythematosus Systemic Lupus Erythematosus (SLE) Systemic lupus erythematosus is a chronic, multisystem, inflammatory disorder of autoimmune etiology, occurring predominantly in young women. Common manifestations may include arthralgias and... read more but who have no clinical or laboratory evidence to confirm such exacerbations.
Treat by emphasizing physical methods, stress management, and sleep improvement, and, when necessary for pain, by giving nonopioid analgesics.
Drugs Mentioned In This Article
|Drug Name||Select Trade|
|Amrix, Fexmid, Flexeril|
|Elavil, Tryptanol, Vanatrip|
|Prudoxin, Silenor, Sinequan, Zonalon|
|7T Gummy ES, Acephen, Aceta, Actamin, Adult Pain Relief, Anacin Aspirin Free, Apra, Children's Acetaminophen, Children's Pain & Fever , Comtrex Sore Throat Relief, ED-APAP, ElixSure Fever/Pain, Feverall, Genapap, Genebs, Goody's Back & Body Pain, Infantaire, Infants' Acetaminophen, LIQUID PAIN RELIEF, Little Fevers, Little Remedies Infant Fever + Pain Reliever, Mapap, Mapap Arthritis Pain, Mapap Infants, Mapap Junior, M-PAP, Nortemp, Ofirmev, Pain & Fever , Pain and Fever , PAIN RELIEF , PAIN RELIEF Extra Strength, Panadol, PediaCare Children's Fever Reducer/Pain Reliever, PediaCare Children's Smooth Metls Fever Reducer/Pain Reliever, PediaCare Infant's Fever Reducer/Pain Reliever, Pediaphen, PHARBETOL, Plus PHARMA, Q-Pap, Q-Pap Extra Strength, Silapap, Triaminic Fever Reducer and Pain Reliever, Triaminic Infant Fever Reducer and Pain Reliever, Tylenol, Tylenol 8 Hour, Tylenol 8 Hour Arthritis Pain, Tylenol 8 Hour Muscle Aches & Pain, Tylenol Arthritis Pain, Tylenol Children's, Tylenol Children's Pain+Fever, Tylenol CrushableTablet, Tylenol Extra Strength, Tylenol Infants', Tylenol Infants Pain + Fever, Tylenol Junior Strength, Tylenol Pain + Fever, Tylenol Regular Strength, Tylenol Sore Throat, XS No Aspirin, XS Pain Reliever|
|Lyrica, Lyrica CR|
|Cymbalta, Drizalma, Irenka|
|Marcaine, Marcaine Spinal, POSIMIR, Sensorcaine, Sensorcaine MPF , Xaracoll|
|7T Lido, Akten , ALOCANE, ANASTIA, AneCream, Anestacon, Aspercreme with Lidocaine, Astero , BenGay, Blue Tube, Blue-Emu, CidalEaze, DermacinRx Lidogel, DermacinRx Lidorex, DERMALID, Ela-Max, GEN7T, Glydo, Gold Bond, LidaMantle, Lidocan, Lidocare, Lidoderm, LidoDose, LidoDose Pediatric, Lidofore, LidoHeal-90, LIDO-K , Lidomar , Lidomark, LidoReal-30, LidoRx, Lidosense 4 , Lidosense 5, Lidosol, LIDO-SORB, Lidotral, Lidovix L, LIDOZION, Lidozo, LMX 4, LMX 4 with Tegaderm, LMX 5, LTA, Lydexa, Moxicaine, Numbonex, ReadySharp Lidocaine, RectaSmoothe, RectiCare, Salonpas Lidocaine, Senatec, Solarcaine, SUN BURNT PLUS, Tranzarel, Xyliderm, Xylocaine, Xylocaine Dental, Xylocaine in Dextrose, Xylocaine MPF, Xylocaine Topical, Xylocaine Topical Jelly, Xylocaine Topical Solution, Xylocaine Viscous, Zilactin-L, Zingo, Zionodi, ZTlido|
|Arthricare for Women, Arthritis Pain Relieving, Capsimide, Capzasin-HP, Capzasin-P, Castiva Warming, Circatrix, DermacinRx Circata, DermacinRx Penetral, DiabetAid, Qutenza, Zostrix, Zostrix HP, Zostrix Neuropathy|