Fibromyalgia

ByDeepan S. Dalal, MD, MPH, Brown University
Reviewed/Revised Mar 2024
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Fibromyalgia is a common, nonarticular, noninflammatory disorder characterized by generalized aching (sometimes severe); widespread tenderness of muscles, areas around tendon insertions, and adjacent soft tissues; muscle stiffness; fatigue; mental cloudiness; poor sleep; and a variety of other somatic symptoms. Diagnosis is clinical. Treatment includes exercise, local heat, stress management, medications to improve sleep, and nonopioid analgesics.

In fibromyalgia, any fibromuscular tissues may be involved, especially those of the occiput, neck, shoulders, thorax, low back, and thighs. Although symptomatic in these areas, 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), 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 diseases, thus complicating diagnosis and management. Bursal areas, such as the pes anserine and trochanteric areas, are commonly affected as part of the generalized pain syndrome, but very local "flares" in fibromyalgia should be evaluated as in patients who do not have fibromyalgia.

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 temporally follow a viral or other systemic infection (eg, Lyme disease or perhaps COVID-19 infection [1]) or a traumatic event, but additional or prolonged antiviral or antibiotic therapy is not indicated because it has not been demonstrated to be effective.

Etiology reference

  1. 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, interstitial cystitis, or migraine or tension headaches. Paresthesias may be present, typically bilaterally and often migratory.

Symptoms can be exacerbated by concomitant disorders such musculoskeletal pain in patients with an inflammatory arthritis (eg, rheumatoid arthritis) or sleep disturbances in patients with obstructive sleep apnea or depression.

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) are variably tender when palpated. The tender areas are not swollen, red, or warm; such findings should suggest an alternative diagnosis.

Diagnosis of Fibromyalgia

  • Clinical criteria

  • 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), 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 of difficulty in 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 and hepatitis C (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, physical examination, and/or routine laboratory tests.

To avoid potential pitfalls, clinicians should consider the following:

Pearls & Pitfalls

Diagnosis reference

  1. 1. Wolfe F, Clauw DJ, Fitzcharles MA, et al: 2016 revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum 46(3):319–329, 2016. doi: 10.1016/j.semarthrit.2016.08.012.

Treatment of Fibromyalgia

  • Stretching and aerobic exercise, local heat, and massage

  • Stress management

  • Nonopioid analgesics

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. Patients should be screened for sleep disorders (eg, obstructive sleep apnea) and other factors that may interfere with sleep. Good sleep hygiene should also be emphasized.

Medications taken by the patient should be reviewed to identify those that may aggravate sleep problems. Such medications should be avoided. Anxiety, depression, and especially bipolar disorder, if present, should be addressed.

biofeedback, massage, hypnotherapy, chiropractic interventions, 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). Although randomized trials and systematic reviews have evaluated some of these therapies against controls, the overall effects of these therapies are small.

Treatment reference

  1. 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.

Prognosis for Fibromyalgia

Fibromyalgia tends to be chronic but may improve 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.

Key Points

  • 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 and hepatitis C, and consider chronic fatigue syndrome and polymyalgia rheumatica. Do further testing for systemic rheumatic diseases only if they are specifically suggested by clinical evaluation.

  • Consider fibromyalgia in patients having apparent painful exacerbations of systemic rheumatic diseases such as rheumatoid arthritis or systemic lupus erythematosus 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.

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