Fibromyalgia

Pertinent History

• Symptoms: Widespread soft tissue pain, persistent fatigue, non-restorative sleep, and ‘fibrofog’ (difficulty concentrating).

• Associated Conditions: Commonly coexists with anxiety, depression, IBS, interstitial cystitis.

• Duration: Chronic, lasting ≥3 months.

Examination

• Tenderness: Soft tissue pressure points (e.g. lateral epicondyles, trapezius).

• Allodynia: Pain response to light touch or inflated BP cuff.

• Normal Findings: Typically no objective joint swelling or systemic abnormality on exam.

Diagnosis

• Criteria (ACR 2010/2016)

  • Widespread Pain Index (WPI) ≥7 and Symptom Severity Score (SSS) ≥5, or

  • WPI 3–6 and SSS ≥9

  • Symptoms present ≥3 months

  • Exclusion of other medical causes

• Labs/Imaging: Conduct only to rule out differentials (e.g. hypothyroidism, inflammatory arthritis).

Management

Non-Pharmacological

• Exercise:

  • Gradual introduction of aerobic or hydrotherapy-based programmes.

  • Pace activities to avoid flare-ups.

• Psychological Support:

  • CBT, mindfulness, or stress management strategies.

  • Can improve coping, reduce catastrophising.

• Sleep Hygiene:

  • Fixed schedule, minimised disturbances.

  • Address possible coexisting insomnia or restless legs.

• Support Networks:

  • Consider referral to fibromyalgia-specific support groups, physiotherapy, occupational therapy, or pain clinics.

Pharmacological

• First Line:

  • Low-dose TCAs (e.g. amitriptyline 10–25 mg nocte) to improve sleep quality and reduce pain.

• Second Line:

  • Duloxetine (SNRI) or pregabalin/gabapentin (gabapentinoids).

  • Titrate doses gradually based on tolerance and effect.

• Avoid Opioids: Generally not beneficial long-term; only tramadol might be considered in specialised settings.

• Goal: Improve functionality and quality of life rather than completely abolish pain.

Counselling Points

• Pain is real but not caused by ongoing tissue damage.

• Symptoms can fluctuate; fibromyalgia is not progressive or life-threatening.

• Emphasis on long-term management goals: better function, improved sleep, coping skills.

• Adherence to exercise, sleep hygiene, and psychological therapies is crucial.

Red Flags

• New onset in older adults (possible malignancy, inflammatory condition).

• Focal pain or neurological deficits not typical of fibromyalgia.

• Systemic signs (weight loss, fever, night sweats) suggest alternative pathology.

When to Refer

• Atypical presentation or refractory symptoms

• Marked psychosocial complexities or severe mental health comorbidities

• Specialist pain clinics or rheumatology if unclear diagnosis or suboptimal response

Differentials

• Rheumatoid arthritis (RA), polymyalgia rheumatica (PMR)

• Chronic fatigue syndrome (CFS)

• Hypothyroidism

• Sleep apnoea or other sleep disorders

Complications

• Functional Impairment: Difficulty maintaining work or daily activities

• Psychological Distress: Depression, anxiety, low self-esteem

Notes

• Often overlaps with other rheumatological or systemic disorders (e.g. SLE, RA).

• First-line drug: Low-dose TCAs. If ineffective, consider duloxetine or a gabapentinoid.

• Gradual exercise and psychological support remain cornerstone therapies.