Fibromyalgia: Treatment

From: 5 minutes consults

Medication (Drugs)

First Line

Pregabalin is the only medication FDA-approved for fibromyalgia.
Amitriptyline 25–50 mg PO HS (1)[A]:
Alternative: Desipramine (less sedating)
Cyclobenzaprine 10–30 mg PO HS (1)[A]

Second Line
NSAIDs less likely to help since there is no identified inflammation, except as adjunctive pain measure
Acetaminophen standard doses
Tramadol 200–300 mg/d PO divided doses (1)[A]
Combinations of the above
Avoid narcotics
Pregabalin 150–450 mg/d PO, b.i.d./t.i.d., start with lower doses; advance as needed (1)[A]
Gabapentin 1,200–2,400 mg/d PO b.i.d./t.i.d.; start with lower doses (1)[A]
Duloxetine 60 mg PO b.i.d (1)[A].
Milnacipran available in US now Trade Name Savella
Fluoxetine 20–80 mg/d PO (higher doses may be needed) (1)[A]
Paroxetine
Fluvoxamine
Clonazepam 0.5 mg PO HS may help sleep
Combinations of medicines such as amitriptyline and fluoxetine may be tried

Additional Treatment

General Measures

Patient understanding of the illness and goals of therapy is key.
Cardiovascular exercise, low impact, is useful as long as the exercise program continues (2)[A].
Cognitive behavioral therapy (1)[A]
Stress management
Patient education; consider group format (1)[A]
Sleep hygiene
Psychosocial support
Consider job/workplace modifications

Issue for Referral
Referrals for nonresponders may go to Rheumatology, Psychiatry, Physiatry, Pain Management Centers

Complementary and Alternative Therapies

Physical therapy may be helpful as part of conditioning program/fitness
Moderate efficacy shown in some studies for:
Acupuncture
Hypnotherapy
Biofeedback
Balneotherapy
Weak efficacy for:
Chiropractic
Massage therapy
Electrotherapy
Ultrasonography