Fibromyalgia

Authored by Dr Mary Lowth, Reviewed by Dr John Cox on | Certified by The Information Standard

Fibromyalgia causes pains and tenderness in many areas of the body, and tiredness. You may also have other symptoms. There is no simple cure. However, there are various treatments that ease symptoms in many cases. Non-medication treatments which may help include exercise (the most highly recommended approach), heated pool treatment, and cognitive behavioural therapy (CBT). Medication that may help includes certain painkillers, including low-doses of antidepressants (used for their pain-relieving effects).

The word fibromyalgia means pain (algia) coming from the muscles (my) and fibrous tissues (fibro) such as tendons and ligaments. Most people with fibromyalgia also have other symptoms in addition to these pains - see below. Therefore, fibromyalgia is sometimes called fibromyalgia syndrome (FMS). It is a persistent (chronic) condition. Fibromyalgia does not affect the joints and so is not an arthritis.

The cause of fibromyalgia is not known, but the most widely accepted theory is that fibromyalgia is a central pain problem, caused by excessive levels of pain stimulators or amplifiers in the central nervous system, in response to triggers in the muscles which should not normally cause pain (because there is no corresponding injury).

Research has shown that people with fibromyalgia have subtle changes in chemicals called neurotransmitters, which are found in the brain and nervous system. These chemicals transmit messages between nerves and between brain cells. This includes an increased amount of a protein called 'substance P', which is both a neurotransmitter and a neuromodulator (it modifies signals in the brain). Substance P is thought to be involved in the way pain messages are transmitted, and may amplify (increase) pain signals. What this means is that the central nervous system in patients with fibromyalgia produces pain signals which would normally indicate injury, in the absence of injury.

This increased level of pain producing neurotransmitters is called central sensitisation. The triggers for these changes are not known, but this means that treating the muscles themselves is not usually an answer - or, at least, not the whole answer. Fibromyalgia does not appear to be due to abnormality or damage to muscles, tendons or ligaments, even though this is where the brain perceives pain and damage to be taking place. Treatments therefore need to focus on modifying pain signals in the central, not the peripheral, nervous system.

Fibromyalgia causes considerable distress and misunderstanding. The condition is a real one, which causes pain and disability and can have an enormous impact on everyday life.

Sometimes, in trying to explain that fibromyalgia is thought to be caused by abnormalities of pain transmitters in the brain and spinal cord (the central nervous system) rather than the peripheral nervous system, doctors can give their patients the impression that their pain is considered to be 'in the mind' (ie imagined).

This isn't the case. The cause of fibromyalgia may lie in the brain, but saying that something occurs in the brain isn't the same as saying it occurs in the mind. The brain is where we process and produce the sensation of pain. After all, nobody would ever suggest that a condition like a stroke, which affects the brain, is in the mind.

Pain is the end result of a nerve and neurotransmitter process, the function of which is to warn us of tissue injury. An abnormality in that process may produce pain without tissue injury. (More rarely, the opposite occurs, and people are born with too little response to pain, which can be a dangerous and harmful state.)

Central sensitisation describes the brain responding differently to nerve signals. It does not represent a 'low pain threshold', as it doesn't appear to be caused by low sensitivity to pain, but by higher-than-average release of central pain chemicals in response to certain triggers in the muscles, like pressure and stretch. Many people with fibromyalgia explain that their pain tolerance in other situations is not reduced at all.

About 1 in 25 people develop fibromyalgia at some stage in their lives. It is very much more common in women than in men. It usually begins between the ages of 25 and 55, and has typically been present for over a year by the time it is diagnosed (sometimes much longer). It is uncommon in children.

Some patients report fibromyalgia beginning after an illness like flu, which causes muscle inflammation and pain. For this reason some people have wondered whether a virus can 'trigger' fibromyalgia by upsetting the way the nerve fibres in muscles react to pressure and stretch. For many patients, though, fibromyalgia comes out of the blue.

The main symptoms are pains felt in many areas of the body, and tiredness (fatigue). Some people also develop other symptoms. The severity of symptoms varies from person to person.

Pain

Pain can occur in any area of the body. Typically, many areas of the body are affected, and some people feel the pain all over. The neck and back are the sites that are often the most painful. The severity of the pain can vary from day to day. The pains may be made worse by stress, cold or activity. After a night's sleep, you may also feel quite stiff for a few hours. Many areas of the body may also be quite tender.

Tiredness

Tiredness is common, and is sometimes severe. In some cases it is more distressing than the pain. It is also common to have a poor sleep pattern. You may wake feeling exhausted. Many people feel worst first thing in the morning but improve by the afternoon. Even a small amount of activity may make you tired. The tiredness may cause you to have poor concentration.

Various other symptoms have been reported by people with fibromyalgia. Also, there are a number of other conditions that often occur at the same time as fibromyalgia. As a consequence, quite a number of other symptoms may occur in people with fibromyalgia. The following are perhaps the most common, but it is not an exhaustive list of every possible symptom that may occur:

Tiredness is a nonspecific symptom - which means it can be a symptom of many different conditions, not just fibromyalgia. See the separate leaflet called Tiredness (Fatigue).

The typical tender points that are used in the diagnosis of myalgia are shown in the diagram below. It is important to remember that everyone's symptoms are different - you may not have this exact distribution of pain points - it is quite common to have many more points than these, or to have some variation in tender points.

A doctor's examination will check for the particularly tender spots on your body. During the examination the doctor may press firmly with a thumb on these areas. The amount of pressure used by the doctor does not cause pain in people without fibromyalgia (or other causes of pain). However, the pressure typically causes people with fibromyalgia to flinch.

This increased sensitivity to pressure (being tender to mild pressure) can be in many places in the body, and may be all over. However, a doctor will usually press on specific sites which are particularly helpful in the diagnosis of fibromyalgia.

To make a firm diagnosis, symptoms need to include widespread pain involving both sides of the body, above and below the waist, as well as the neck, back and pelvis, and to have been present for at least three months.

Fibromyalgia tender points

Fibromyalgia is usually diagnosed by the typical symptoms and a doctor's examination.

Apart from finding multiple areas of tenderness, the examination by a doctor will usually find no other abnormality.

There is no laboratory test that confirms the condition. It is diagnosed on the history (the symptoms that you describe to your doctor) and the typical findings of tenderness. The presence of the other symptoms listed above tends to support the diagnosis.

Many of these symptoms are 'nonspecific' - which means they are found in other conditions such as irritable bowel syndrome, medication headache, Addison's disease and obstructive sleep apnoea. However, if they all occur together, at the same time as pressure point tenderness, they suggest a diagnosis of fibromyalgia.

On the other hand, if you have other noticeable symptoms which are not on the list - for example joint swelling, or fever, or weight loss - those do not support a diagnosis of fibromyalgia, and your doctor is likely to look for other causes of your symptoms.

If your doctor is not certain, perhaps because your symptoms are not typical, or because you are particularly tired, they may want to do some simple blood tests to rule out other diseases that can cause similar symptoms, such as an underactive thyroid gland, early osteoarthritis, rheumatoid arthritis, or anaemia.

There is no cure for fibromyalgia. Treatments aim to reduce symptoms as much as possible. Over the years several different treatments have been advocated, with variable rates of success.

Fibromyalgia has been quite intensively studied by scientists and clinicians trying to find the best treatment, in order to determine which treatments should be recommended. Their recommendations were based on reviewing the results of research that had shown a treatment to be beneficial to at least some people with fibromyalgia. They published a guideline called 'EULAR evidence-based recommendations for the management of fibromyalgia syndrome'. It was first published in 2005 but is regularly updated, the last time in 2017. EULAR makes a number of recommendations, and these are briefly mentioned below.

Each person is different and has different symptoms. Not all treatments help in all cases, and not all treatments may be locally available. Your doctor is likely to discuss the pros and cons of the various options, and help you to decide which is the best option (or options) to try. Most people need a combination of treatments: this won't always include medication, but it may do. Treatment should be tailored to you according to how your fibromyalgia affects you, and what additional symptoms you have.

The latest EULAR view of the best way to approach fibromyalgia assesses the evidence for many therapies, which are discussed further below. Medicine is a science of probabilities - nobody can tell you what will certainly work for you. Evidence aims to tell us what tests and research might work, how likely it is to work, and how well it might work.

Evidence on fibromyalgia suggests the following:

The approach with the best results in the most people is exercise. This means a graduated approach, as detailed below.

Alternative medicines

Some people try complementary or alternative treatments such as aromatherapy, massage, etc. There is little evidence that such treatments relieve the core symptoms of fibromyalgia. However, some people find that certain treatments help them to relax, feel less stressed and feel better in themselves, which helps them to cope better with their condition.

Exercise

Exercise does not always help but it improves symptoms in a high proportion of cases. If you are able, consider gradually building up to more and more exercise. Aerobic exercises which cause very little pounding, such as walking, cycling and swimming, and resistance exercises (which are strengthening with no pounding impact at all) are thought to be best. Stretching exercises such as yoga may also help.

EULAR recommend this strongly. If you have tried exercise before, and made things worse, then it may be that you overdid it, or used the wrong exercises. A physiotherapist, particularly one with an interest in fibromyalgia, may be able to offer you guidance and advise on a suitable programme for your particular circumstances.

The aim is to exercise safely and without increased pain. A typical goal to aim for is to build up exercise to 4-5 times a week for at least 20 to 30 minutes a session, but it depends where you are starting from. It may take several months to build up to this level.

One study describes how people with fibromyalgia were prescribed an exercise class - mostly walking on treadmills, or using exercise bicycles. Each person was encouraged to increase the amount of exercise gradually. When people first started they typically did two sessions of exercise per class, lasting about six minutes. By three months some people had increased to doing two sessions in each class lasting 25 minutes. At three months, about 1 in 3 people who did the exercise programme rated themselves as much better.

Note: pain and stiffness can get worse for a short while when you first start on an exercise programme.

Heated pool treatment with or without exercise

Heated pool treatment (balneotherapy) has been shown to improve symptoms in some cases. Some trials that looked into this included exercise in addition to heated pool treatment, and some looked at heated pool treatment alone. Each seemed to help in some cases.

One study of fibromyalgia patients, who received 20 minutes' bathing, once a day, five times per week, for three weeks (total of 15 sessions), suggested that, on average, the treatment resulted in significantly less tenderness and pain for as long as six months after the treatment had finished.

Your doctor or physiotherapist may recommend a locally based heated hydrotherapy pool. However, if none is available, a heated swimming pool, or jacuzzi may suffice, and simply lying in a warm bath for 20 minutes per day may also be of benefit.

Cognitive behavioural therapy (CBT)

CBT may be of benefit to some people with fibromyalgia. CBT is a type of talking treatment (psychotherapy) used as a treatment for various mental health and physical problems. Unlike other types of psychotherapy it does not involve dwelling on events in your past. CBT tends to deal with the way your thoughts and behaviours are affecting the way you feel.

CBT is problem-focused and practical. There is evidence that it helps to ease pain symptoms, as well as reducing their effect on your life. This is thought to be because the parts of the brain that control the way we respond to unpleasant things can be modified by CBT, so it may affect the way your brain responds to the false pain signals which it is receiving.

There is a lot of evidence in favour of CBT, although the trials themselves were not felt to be of high scientific quality, so EULAR recommend this treatment cautiously. It is unlikely to cause harm, but its benefit is not clearly proved.

Other therapies

Other therapies that show evidence of being useful for pain and tiredness in some patients include relaxation, acupuncture and psychological support. All of these may increase the levels of endorphins (which are effectively natural painkillers) in the central nervous system so that symptoms become more tolerable and activity levels can increase. Limited evidence suggested that meditation is helpful for sleep and fatigue.

Therapies which were not found to be useful, on reviewing trial evidence, include chiropractic treatment, biofeedback, hypnotherapy and massage. 

Painkillers

Painkillers - such as paracetamol, anti-inflammatory painkillers such as ibuprofen, or stronger painkillers such as codeine - are often tried to ease pain. However, they often do not work very well in fibromyalgia. Anti-inflammatory painkillers, in particular, showed no evidence for benefit, and can themselves be harmful if used in the long term.

Tramadol is a stronger painkiller which does seem to be of benefit in fibromyalgia, particularly when used with paracetamol. It is recommended if paracetamol alone is not helpful.

Very strong opiate painkillers such as morphine are not recommended. This is because fibromyalgia is a long-term condition. It is unwise to take strong opiates long-term, as they can lead both to problems with medication dependence, and to a general impairment in the performance of your mind and brain - things such as memory, mental agility and alertness.

Antidepressants

Antidepressant medicines are sometimes helpful for fibromyalgia, because they also function as painkillers. This is probably because antidepressants modify levels of neurotransmitters, and pain and depression involve the same neurotransmitters working in different but closely related parts of the brain.

Antidepressants may help with easing pain and improving overall function, and may also help with disturbed sleep.

Some people with fibromyalgia will feel that, in offering them an antidepressant, their doctor is failing to appreciate that their main symptom is pain. This isn't the case - the problem is that antidepressants are also anti-central (or brain) pain, but that isn't reflected in their name. Antidepressant medicines are used to treat various conditions apart from depression.

Tricyclic antidepressants ease pain separately to their action on depression. They can be helpful in fibromyalgia, both for pain and for insomnia, with patients who benefit reporting their pain scores down by an average of about a third. A trial of 4-6 weeks of low-dose amitriptyline is often advised, and continued if found to be helpful. Only low doses are used (the dose is very low when compared to a dose that may be used to treat depression).

Selective serotonin reuptake inhibitors (SSRIs) and the closely related serotonin-norepinephrine reuptake inhibitors (SNRIs) show mixed results in fibromyalgia. SSRIs, which include fluoxetine (Prozac®), seem not to be of benefit, whereas some SNRIs including duloxetine, do appear to show benefit for pain, in some patients.

There are other antidepressants to these, but none for which there is good evidence in fibromyalgia.

Sleeping tablets

These are not often used, as they do not help with fibromyalgia, and can be addictive. See separate leaflet called Insomnia (Poor Sleep) for tips on getting a good night's sleep.

Sodium oxybate, a medicine used to treat narcolepsy, has also been tested, but has been found not to be effective.

Muscle relaxants

One study examine the effects of a medicine called cyclobenzaprine, which is a muscle relaxant. It seemed to help sleep slightly, but not pain - and this was at the expense of significant side-effects in most patients.

Other medicines

Unusual painkilling medicines called pregabalin and gabapentin have been shown to help some people with fibromyalgia. Although there are relatively few studies.

One study, surprisingly, considered using human growth hormone, but it did not prove beneficial and there are safety concerns regarding its use in adults, in whom it can have long-term effects such as high blood pressure, diabetes and increased muscle pains.

Capsaicin gel

Capsaicin gel can be purchased in health-food shops. EULAR concluded there was no evidence suggesting it is helpful for the symptoms of fibromyalgia.

If you have depression in addition to fibromyalgia, as some people do, then a full-strength dose would be appropriate to treat both the pain of the fibromyalgia and the depression. 

Many people with fibromyalgia feel they have sensitivities to particular foods, particularly if they also have irritable bowel syndrome (IBS). If you think that foods may aggravate your symptoms, try keeping a daily food journal. You could also try an elimination challenge diet, in which you stop eating a certain food for a few weeks, then add it back to your diet to see how you feel.

Make sure you don't miss out on essential nutrients when you do this. Try to eat a well-balanced diet high in fruits, vegetables, whole grains, and lean protein.

If you're struggling with pain and exhaustion, it's hard to cook nutritious meals. Try eating small meals frequently throughout the day - and always eat breakfast, which should include some protein and slow-release carbohydrate, which will give you the right kind of energy to get you going through the morning, even if your body is aching and you're feeling tired.

There is some overlap of symptoms between fibromyalgia and lupus, as both can cause pain and tiredness.

People with fibromyalgia are not more likely to get lupus. However, people who have lupus have an increased tendency to additionally develop fibromyalgia, so it is possible to have both disorders.

Lupus affects skin, joints and other body organs. It usually produces more visible signs than fibromyalgia. It is usually diagnosed on blood testing - certain blood tests that are normal in fibromyalgia are abnormal in lupus. See the separate leaflet called Lupus (Systemic Lupus Erythematosus).

Fibromyalgia can last a short or a long time. It can make life extremely tough, but it does not shorten your life. In some cases, symptoms ease or go after a few months. However, in many cases it is a persistent (chronic) condition which tends to wax and wane in severity, with a severe effect on your quality of life.

Further reading and references

Reasons you feel tired all the time

hi, I was on DLA and received a pip form in June ,my dla suppose to be indefinite they're liars .i send all the evidences of my illness I'm bed bound and under the mental health for years .and...

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