What is the treatment for fibromyalgia?
There are both medication and non-medication treatments for fibromyalgia. Medication treatments frequently help manage the pain and sleeplessness from which fibromyalgia patients suffer. However, the non-medication treatments are really the basis of treatment for fibromyalgia. The non-medication treatments for fibromyalgia include education, exercise, and stress reduction. Sleep disorders may require both medication and non-medication treatments.
Education about fibromyalgia is very important. Often patients have suffered with symptoms for years, and simply knowing why they have pain can be a relief, as many patients become anxious not knowing what is causing their symptoms. Patients should also be educated about treatment approaches, good sleep hygiene, and the importance of treating conditions that may contribute to their symptoms. For example, when a patient with rheumatoid arthritis has fibromyalgia as well, poor control of their rheumatoid arthritis may lead to worsening of fibromyalgia pain and sleeplessness.
An exercise program is crucial in the treatment of fibromyalgia and should include stretching, strengthening, and aerobic exercise. Many patients with fibromyalgia find it difficult to institute a regular exercise program because they feel they are too tired to exercise and they may perceive that their pain and fatigue worsen when they begin to exercise. However, numerous scientific studies have shown that exercise for fibromyalgia, especially aerobic exercise, can improve pain, physical function, and a sense of well-being. Starting slow and sticking with the exercise program is very important. Low-impact aerobic activities such as swimming, water aerobics, walking, and biking are activities that patients with fibromyalgia find helpful. Many patients find it helpful to exercise in the morning. Some patients find yoga helpful for strengthening and stretching. An aerobic exercise program should also accompany this.
Stress reduction is important for the self-management of fibromyalgia symptoms. Many patients feel that their symptoms are triggered by stress. Stress reduction can be challenging. There are many stressors in life; some can be changed and others cannot. Stress reduction involves a combination of changing stressors that can be changed and learning to lessen the body’s stress reaction to the stressors that cannot be changed.
Cognitive behavioral therapy is a form of psychological therapy whereby a therapist and patient work together, to establish healthy patterns of behavior by replacing negative thoughts with more productive thoughts and actions. This has been proven to work in fibromyalgia. This form of therapy can be done one on one in an office setting, or even over the Internet.
The non-medication therapies are the cornerstone of treatment for fibromyalgia. With them, many people improve and may not require medications. Moreover, without focusing on sleep hygiene, stress reduction and exercise, it is difficult to improve, even with medication.
When used with non-medication therapies, medication treatments can help improve sleep, pain, and function in fibromyalgia. Administration of medications is most effective for pain relief when combined with ongoing non-medication treatments as discussed above. Medications often used in the treatment of fibromyalgia include medications in the antidepressant class (medications originally developed to treat anxiety and depression) and anticonvulsants (medications originally developed to treat seizures).
- Medications called “tricyclic antidepressants” have been used to treat fibromyalgia for many years. These medications include amitriptyline (Elavil), doxepin (Sinequan, Silenor), and desipramine (Norpramin). These medications are generally started in low doses and increased until adequate response is achieved. The advantage of these medications is that they are effective for sleep and pain, widely available, and less costly for most patients than some of the newer agents. Cyclobenzaprine (Flexeril) is a medication that is both a muscle relaxant and tricyclic antidepressant that can be used to help with sleep and pain in patients with fibromyalgia.
- Medications in the antidepressant class that affect the serotonin and the norepinephrine neurotransmitters (SNRI antidepressants) are frequently used in the treatment of fibromyalgia. These medications include duloxetine (Cymbalta), milnacipran (Savella), and venlafaxine (Effexor). Norepinephrine is a neurotransmitter in the brain, and increasing the levels of norepinephrine with these medications decreases pain levels. Fluoxetine (Prozac) is an antidepressant that affects mainly serotonin at low doses but increases norepinephrine as well at higher doses. Higher doses of fluoxetine can be used to treat fibromyalgia pain.
- Pregabalin (Lyrica) and gabapentin (Neurontin) are anticonvulsants (medications initially developed to treat seizures). There are many scientific studies showing that pregabalin and gabapentin can be effective for fibromyalgia pain.
- Tramadol (Ultram) is an opioid pain reliever, which is helpful in some patients with fibromyalgia but should be used with caution as sometimes the use of opioids can worsen the pain cycle in fibromyalgia.
- Memantine (Namenda) is a medication commonly used for dementia. Preliminary studies show that memantine may be helpful with pain and other symptoms of fibromyalgia, but further studies are needed to confirm this.
- There have been small scientific studies of low-dose naltrexone (Revia, Vivitrol) in fibromyalgia. Naltrexone’s main scientifically proven use is in treating narcotic addiction. In one small study, a very low dose of naltrexone was shown to benefit some patients with fibromyalgia. Further studies of low-dose naltrexone in fibromyalgia are needed to know if it really works.
A few notes on other treatments for fibromyalgia: Acupuncture can be helpful for some patients with fibromyalgia but is not usually recommended as one of the first-line treatments for fibromyalgia because the scientific studies on acupuncture for fibromyalgia patients have not shown definite benefit. Likewise, trigger point injections help for some patients. Alternative medicines have not been proven to be helpful in fibromyalgia; in particular, scientific studies on guaifenesin (Mucinex) show that it does not work. Of note, patients with vitamin D deficiency can have widespread arthralgia and myalgia, like fibromyalgia, which improves with vitamin D supplementation. While having a sufficient level of vitamin D is important to maintain bone health, a healthy immune system, and perhaps prevent certain types of cancer, vitamin D supplementation does not improve fibromyalgia symptoms in patients who have sufficient levels of vitamin D. Narcotic pain medications should be avoided in fibromyalgia because they may worsen the underlying problem.