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This article is for Medical Professionals

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Fibromyalgia article more useful, or one of our other health articles.

Read COVID-19 guidance from NICE

Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.

Synonyms: fibromyalgia syndrome, fibrositis

Fibromyalgia is a chronic pain disorder. The cause of fibromyalgia is unknown, but there is some evidence for a genetic predisposition, abnormalities in the stress response system or hypothalamic-pituitary axis, and possible triggering events.[1]

  • It is thought that the condition is common and underdiagnosed.
  • The estimated prevalence in America and other countries is 2-3%.
  • Women are 10 times more commonly affected than men.
  • Usual age of presentation is 20-50 years but it has been diagnosed in children, adolescents and older people.
  • There is a link to failing to complete education, low income and being divorced.
  • It is more common in people who have a rheumatic disease.
  • The exact pathophysiology is not known. Hypotheses include:
    • Peripheral and central hyperexcitability at spinal or brainstem level.
    • Altered pain perception.
    • Somatisation.
  • The nociceptive system has links with the stress regulating, immune and sleep systems which may explain some of the clinical features.[4] Recent studies have postulated the involvement of mast cells and their products, such as tumour necrosis factor (TNF), interleukin (IL)-1 and IL-6, which cause hyperalgesia in rodents. Several studies have also reported an association between reduced levels of 25 hydroxyvitamin D3 (25(OH)D3) and chronic pain in patients with arthritis and fibromyalgia.[5]
  • Research has reported a consistent association among genetic factors, psychological symptoms and pain associated with fibromyalgia.[6]

Symptoms of fibromyalgia are chronic widespread pain associated with unrefreshing sleep and tiredness. Fibromyalgia is not a diagnosis of exclusion and often occurs in patients with other conditions, such as inflammatory arthritis and osteoarthritis.[7] The patient may complain of:

  • Pain at multiple sites. Low back pain with/without radiation to the buttocks and legs and pain in the neck and across the shoulders are common complaints.[2] Patients may complain of "pain all over".
  • Fatigue.
  • Sleep disturbance (sleep may exacerbate symptoms and contribute to depression).[8]
  • Morning stiffness.
  • Paraesthesiae.
  • Feeling of swollen joints (with no objective swelling).
  • Problems with cognition (eg, memory disturbance, difficulty with word finding).
  • Headaches (may be migrainous).
  • Light-headedness or dizziness.
  • Fluctuations in weight.
  • Anxiety and depression.

Symptoms are generally reported as worse in cold, humid weather and under times of stress.[2]

  • The American College of Rheumatology produced classification criteria for fibromyalgia. However, these criteria are not meant to be used for diagnosis.

A patient fulfils the diagnostic criteria for fibromyalgia if the following three conditions are met:

  • Widespread pain index (WPI) is 7 and symptom severity (SS) scale score is 5, or WPI equals 3 to 6 and SS scale score of 9.
  • Symptomatology has been present at a similar level for at least three months.
  • The patient does not demonstrate any other disorder that would otherwise explain the pain.

The WPI and the SS scale

  • WPI: note the number of areas where and in how many areas the patient has had pain during the previous week. The score will be between 0 and 19. Areas include shoulder girdle, left hip (buttock, trochanter), left jaw, left upper back shoulder girdle, right hip (buttock, trochanter), right jaw, right lower back upper arm, left upper leg, left chest neck upper arm, right upper leg, right abdomen lower arm, left lower leg, left lower arm, right lower leg, right,

  • SS scale score: the symptoms to focus on are fatigue, waking unrefreshed and cognitive symptoms. For the each of the three symptoms, indicate the severity level over the past week utilising the following scale: 0 no problem; 1 slight or mild problems, generally mild or intermittent ; 2 moderate, considerable problems, often present and/or at a moderate level; 3 severe: pervasive, continuous, life-disturbing problems. Considering somatic symptoms in general, indicate whether the patient has: 0 for no symptoms, 1 a few symptoms, 2 a moderate number of symptoms; 3 for many symptoms. The SS scale score is calculated by adding the severity of the three symptoms (fatigue, waking unrefreshed, cognitive symptoms) plus the severity) of general somatic symptoms. The final score is between 0 and 12.

  • Routine blood testing can help to exclude other differential diagnoses: eg, ESR, TFTs, antinuclear antibodies. However, be careful not to over-investigate.
  • Peripheral nerve dysfunction is increasingly being associated with the pathophysiology of fibromyalgia, small nerve fibre neuropathy being identified as being central to the aetiology of this condition. Electrodiagnostic study, including testing of distal (sural and plantar) nerve action potentials and quantitative sudomotor axon reflex testing, has been used in the research arena, and may well be incorporated into mainstream investigative procedures in the future.[9]
  • The Fibromyalgia Impact Questionnaire can be used to assess function.[10] It also has a role in review and assessment of treatment interventions.
  • A full social, personal, family and psychological history should be taken. There may be an interplay with stress, psychosocial experiences, the psychosocial situation and sociocultural factors.

The aim of treatment is not to cure fibromyalgia but to reduce symptoms and improve quality of life. Individual drugs are often ineffective or cause side-effects so it is important to consider a change in drug or a switch to non-drug approaches - eg, cognitive behavioural therapy or exercise.[7]

General points

  • Pain and function should be assessed in a psychosocial context.
  • A multidisciplinary approach to treatment should be used. GPs, rheumatologists, physicians experienced in dealing with chronic pain, psychologists, psychiatrists, physiotherapists, etc, may all need to be involved.[11]
  • Treatments should be discussed with the patient and tailored to their individual needs, including pain levels, function and associated features such as depression, fatigue and sleep disturbance.

Non-drug treatments

  • Exercise programmes including aerobic exercise and strength training may help some patients with fibromyalgia.[4] The Ottawa Panel also recommends aerobic fitness and strengthening exercise for the management of fibromyalgia.[12, 13]
  • A Cochrane review reports 'gold-level evidence' that moderate-intensity supervised aerobic exercise improves overall well-being and physical function in fibromyalgia.[14] From a practical point of view, they recommend:
    • Slowly increasing the intensity of exercise.
    • If symptoms worsen, cutting back on exercise until symptoms improve.
  • There is some evidence that aquatic training is beneficial for improving wellness, symptoms and fitness levels in adults with fibromyalgia.[15]
  • Moderate to high intensity resistance training may improve function, pain, tenderness and muscle strength in women with fibromyalgia.[16]
  • Cognitive behavioural therapy may help some patients with fibromyalgia.[17]
  • Therapies including relaxation, rehabilitation, physiotherapy and psychological support may help some people with fibromyalgia.
  • A Cochrane review of acupuncture for fibromyalgia concluded:[18]
    • There is low- to moderate-level evidence that acupuncture improves pain and stiffness in people with fibromyalgia.
    • There is moderate-level evidence that the effect of acupuncture does not differ from sham acupuncture in reducing pain or fatigue, or improving sleep or global well-being.
    • Electro-acupuncture (EA) is probably better than manual acupuncture (MA) for pain and stiffness reduction and improvement of global well-being, sleep and fatigue. The effect lasts up to one month, but is not maintained at follow-up after six months.
    • MA probably does not improve pain or physical functioning.
    • Acupuncture appears safe. People with fibromyalgia may consider using EA alone or with exercise and medication.
    • Small sample size, scarcity of studies for each comparison, and lack of an ideal sham acupuncture weakened the level of evidence and its clinical implications.

Drug treatment

  • The National Institute for Health and Care Excellence (NICE) has issued new guidance on chronic pain.[19] It centres largely on the diagnosis and management of chronic primary pain, such as that seen in fibromyalgia. The main tenets of the guidance include:

    • The importance of a multidisciplinary approach.
    • The encouragement of self-management from an early stage of a pain condition and as part of a long-term management strategy.
    • Focus on non-pharmacological management.
    • Treatment aimed at improving function (with realistic goals) and changing pain behaviour.
    • Minimising or if possible avoiding use of opioids for chronic primary pain.
    • Recognition of the potential for dependence with pregabalin, gabapentin.
    • Cannabis-based medicinal products should not be used for managing chronic pain.
    • Consider an antidepressant, either amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline for chronic primary pain.
    • Do not initiate any of the following medicines to manage chronic primary pain:
      • Antiepileptic drugs, including gabapentinoids (eg, gabapentin or pregabalin).
      • Antipsychotic drugs.
      • Benzodiazepines.
      • Corticosteroid, or local anaesthetic/corticosteroid combination, trigger point injections.
      • Ketamine.
      • Local anaesthetics (topical or intravenous).
      • Non-steroidal anti-inflammatory drugs.
      • Opioids.
      • Paracetamol.

    Please see the separate Chronic Pain article for more details.

  • Corticosteroids are not recommended. This is due to the lack of evidence from clinical trials and the long-term side-effects.
  • Co-enzyme Q, a food supplement which enhances mitochondrial activity, has been shown in randomised controlled trials to be useful in combating fatigue and other symptoms associated with fibromyalgia.[20]

Editor's note

Dr Krishna Vakharia, 11th May 2022

NICE guidance: Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults

NICE has published guidance on safe prescribing and withdrawal of medicines associated with dependence or withdrawal symptoms in adults. It has concentrated on benzodiazepines and Z drugs, opioids, gabapentin and pregabalin and antidepressants.[21]

It has brought out a series of recommendations to discuss and review with a patient when initiating and withdrawing medication, as well as guidance on how to reduce risk of dependence.

Whilst antidepressant medication is not known for dependence, it is associated with withdrawal symptoms and this guidance can mitigate these.

Guidance on discussion and documentation; these should include:

  • The medication, common side-effects and how they may change over time.
  • The risk of dependence and how it will be managed.
  • The type of medication and why it has been prescribed.
  • The starting dose and when and if doses will be adjusted.
  • Who to contact if any queries or concerns.
  • How long the medication will take to work and how long you will stay on it for.
  • How long the prescription given is for - eg, one week, two weeks etc.
  • The risks of overdose.
  • Review date.

Recommendations for withdrawal:

  • If there is no benefit or it is no longer beneficial.
  • There are symptoms and signs of dependence.
  • The condition is resolved.
  • There are more harms than benefits to taking the medication.
  • Patient request.

Withdrawal of medication should be done slowly (unless an emergency) taking in factors such as length of time on the medication, how high the dose is (may need to reduce dose first) or any social factors that will affect medication cessation.

  • Awareness surrounding fibromyalgia has risen in recent years.
  • Fibromyalgia continues to be associated with substantial socio-economic loss.[22]
  • It is difficult to predict the prognosis of fibromyalgia, due to the complex interplay of the social and psychological factors in the pathophysiology and symptomology of this condition.

Further reading and references

  1. Fitzcharles MA, Ste-Marie PA, Pereira JX; Fibromyalgia: evolving concepts over the past 2 decades. CMAJ. 2013 Sep 17185(13):E645-51. doi: 10.1503/cmaj.121414. Epub 2013 May 6.

  2. Chakrabarty S, Zoorob R; Fibromyalgia. Am Fam Physician. 2007 Jul 1576(2):247-54.

  3. Bhargava J, Hurley JA; Fibromyalgia

  4. EULAR revised recommendations for the management of fibromyalgia; European League Against Rheumatism (2017)

  5. Alciati A, Nucera V, Masala IF, et al; One year in review 2021: fibromyalgia. Clin Exp Rheumatol. 2021 May-Jun39 Suppl 130(3):3-12. Epub 2021 May 13.

  6. Ferrera D, Mercado F, Pelaez I, et al; Fear of pain moderates the relationship between self-reported fatigue and methionine allele of catechol-O-methyltransferase gene in patients with fibromyalgia. PLoS One. 2021 Apr 2816(4):e0250547. doi: 10.1371/journal.pone.0250547. eCollection 2021.

  7. Rahman A, Underwood M, Carnes D; Fibromyalgia. BMJ. 2014 Feb 24348:g1224. doi: 10.1136/bmj.g1224.

  8. Bigatti SM, Hernandez AM, Cronan TA, et al; Sleep disturbances in fibromyalgia syndrome: relationship to pain and depression. Arthritis Rheum. 2008 Jul 1559(7):961-7.

  9. Lawson VH, Grewal J, Hackshaw KV, et al; Fibromyalgia syndrome and small fiber, early or mild sensory polyneuropathy. Muscle Nerve. 2018 Nov58(5):625-630. doi: 10.1002/mus.26131. Epub 2018 Apr 26.

  10. Fibromyalgia Impact Questionnaire; Fibromyalgia Information Foundation

  11. Hauser W, Bernardy K, Arnold B, et al; Efficacy of multicomponent treatment in fibromyalgia syndrome: a meta-analysis of Arthritis Rheum. 2009 Feb 1561(2):216-24.

  12. Brosseau L, Wells GA, Tugwell P, et al; Ottawa Panel evidence-based clinical practice guidelines for aerobic fitness exercises in the management of fibromyalgia: part 1. Phys Ther. 2008 Jul88(7):857-71. Epub 2008 May 22.

  13. Brosseau L, Wells GA, Tugwell P, et al; Ottawa Panel evidence-based clinical practice guidelines for strengthening exercises in the management of fibromyalgia: part 2. Phys Ther. 2008 Jul88(7):873-86. Epub 2008 May 22.

  14. Busch AJ, Barber KA, Overend TJ, et al; Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev. 2007 Oct 17(4):CD003786.

  15. Bidonde J, Busch AJ, Webber SC, et al; Aquatic exercise training for fibromyalgia. Cochrane Database Syst Rev. 2014 Oct 2810:CD011336. doi: 10.1002/14651858.CD011336.

  16. Busch AJ, Webber SC, Richards RS, et al; Resistance exercise training for fibromyalgia. Cochrane Database Syst Rev. 2013 Dec 2012:CD010884. doi: 10.1002/14651858.CD010884.

  17. Bennett R, Nelson D; Cognitive behavioral therapy for fibromyalgia. Nat Clin Pract Rheumatol. 2006 Aug2(8):416-24.

  18. Deare JC, Zheng Z, Xue CC, et al; Acupuncture for treating fibromyalgia. Cochrane Database Syst Rev. 2013 May 315:CD007070. doi: 10.1002/14651858.CD007070.pub2.

  19. Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain; NICE Guidance (April 2021)

  20. Testai L, Martelli A, Flori L, et al; Coenzyme Q10: Clinical Applications beyond Cardiovascular Diseases. Nutrients. 2021 May 1713(5). pii: nu13051697. doi: 10.3390/nu13051697.

  21. Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults; NICE guidance (April 2022)

  22. Busse JW, Ebrahim S, Connell G, et al; Systematic review and network meta-analysis of interventions for fibromyalgia: a protocol. Syst Rev. 2013 Mar 132:18. doi: 10.1186/2046-4053-2-18.

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