Fibromyalgia

Sonia Nagda, National Center for Health Research

Sonia Nagda MD, Emma Roy, and Diana Zuckerman PhD,  National Center for Health Research

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What Is Fibromyalgia and How Do I Know If I Have It?

Approximately 4 million Americans suffer from fibromyalgia.1 Fibromyalgia is a chronic illness that affects muscles in every part of the body, resulting in widespread pain and stiffness, sleep disturbances, cognitive and emotional issues, and chronic fatigue.1,2

How can you tell the difference between everyday aches and pains and fibromyalgia? Hallmark symptoms of fibromyalgia include the following:

  • Widespread pain throughout the body for at least three months. To be considered widespread, the pain must occur on both sides of your body and above and below your waist.3,4 Pain has to occur in several of the 18 specific areas throughout the body
  • Moderate to severe symptoms of fatigue; waking up feeling unrefreshed
  • Difficulties with attention and performing “tasks that require rapid changes in thought”5
  • No other illness or injury that can explain the pain and other symptoms4

Fibromyalgia can be mistaken for other illnesses, such as myofascial pain syndrome, which consists of muscle pain in the head, neck, and torso; chronic fatigue syndrome; or hypothyroidism (low thyroid hormone).4 However, unlike fibromyalgia, which can be accompanied by depression or anxiety, myofascial pain syndrome is not linked to mood or mental health changes. Chronic fatigue syndrome also involves pain and tiredness, but the pain is caused by inflammation, which is not the case for fibromyalgia. Hypothyroidism can affect a person’s mind, mood, and body similar to fibromyalgia, but it usually includes other symptoms that are unique to having low thyroid hormones. Fibromyalgia has been a controversial diagnosis in the past but is now recognized as a disorder by the National Institutes of Health.6  It can be diagnosed by a primary care physician (PCP), neurologist, pain specialist, or rheumatologist. A health provider will conduct a  physical examination, as well as possible blood tests and imaging, to determine if you have fibromyalgia or another disorder.

If you have any of the signs and symptoms of fibromyalgia, contact your healthcare provider to discuss these symptoms and request a physical exam.

 

What Causes Fibromyalgia and Who is at Risk?

Researchers are unaware of the causes of fibromyalgia, but some believe the symptoms are related to altered neural pathways and that “fibromyalgia amplifies painful sensations by affecting the way your brain and spinal cord process pain signals.”2,3   Emotional stress, medical illness, surgery, or trauma can trigger fibromyalgia. 4 Women are far more likely than men to get fibromyalgia. In fact, for every man with the fibromyalgia, seven women are diagnosed.7

Fibromyalgia is also more common in people with anxiety and depression. Fibromyalgia patients are five times as likely to suffer from depression as people in the general public.8 Chronic stress and feelings of sadness can worsen the pain symptoms of fibromyalgia. Additionally, people diagnosed with fibromyalgia often have a history of abuse and sleep disorders. 4 More than half of patients with fibromyalgia also suffer from migraine headaches.4 Other illnesses that put individuals at risk for developing fibromyalgia like lupus, rheumatoid arthritis, and osteoarthritis.3 These health problems that tend to go hand-in-hand with fibromyalgia can greatly harm the quality of life for these patients.9

 

Treating Fibromyalgia

While there is no cure for fibromyalgia, some people have been able to reduce or control certain symptoms with appropriate treatments.

Medication Options:

Currently, there are three drugs approved by the Food and Drug Administration (FDA) for the treatment of fibromyalgia: duloxetine (brand name Cymbalta, an antidepressant), pregabalin (brand name Lyrica, a neurological drug used to treat pain from damaged nerves), and milnacipran (brand name Savella, a drug that is similar to Cymbalta that has been approved by the FDA to treat fibromyalgia but not depression).9 Cymbalta was shown to reduce pain in 42% of patients, compared with 32% taking a placebo. Although statistically significant, this comparison shows how subjective pain is and how effective a placebo can be. However, it was found that some of the patients in this systematic review dropped out of the studies because of the side effects from the medication , which can include difficulty sleeping and reduced interest in sexual activity.10  Nevertheless, patients need to be cautious about stopping Cymbalta because there are withdrawal symptoms common to many antidepressants, such as nausea and dizziness.  Withdrawal can also cause ‘Brain Zaps’, which feel like “an electrical shock sensation to the brain”.11 Patients can reduce the likelihood of experiencing these withdrawal symptoms by  tapering off the medication rather than stopping cold turkey. That is why experts recommend consulting with your healthcare provider before stopping any medication.

Analysis of clinical trials using different doses of Lyrica showed that it worked for only 9% to 14% of fibromyalgia patients.12  Approximately the same percentage stopped taking Lyrica because of the side effects. Savella is the only drug approved by the FDA specifically for fibromyalgia and not any other illnesses.13 However, it does not work well long-term for many individuals, which is a major shortcoming because fibromyalgia is a life-long disease. In addition, there are many serious side effects of Savella: high blood pressure, liver damage, male sexual dysfunction, suicidal ideation, and harm to the fetus in pregnant animals. These side effects were not known when Savella was initially approved by the FDA. In summary, although it can be worth trying for some patients, for many, the side effects are worse than the benefits.

Additional medications that are sometimes given to fibromyalgia patients include other antidepressants, muscle relaxants, and pain medications.4,7 Because the brain pathways that cause pain and depression are similar, many patients take antidepressants to get some relief from both symptoms. For example, a 2021 study of 11,930 fibromyalgia patients reported that the antidepressant amitriptyline helped improve “sleep, fatigue, and health-related quality of life outcomes.”14

Alternatives to Medication:

Researchers are studying the possible benefit of  regenerative injection therapy (RIT), which includes prolotherapy and PRP, to reduce complex pain experienced by fibromyalgia patients.15,16 RIT is an injection that can be made up of one’s own plasma or an irritant, such as glucose solution, and is injected into the affected muscle area, with the goal of helping to form new healthy tissue. While it was typically used for sports-related injuries and arthritis, research has suggested it may be effective for the chronic pain experienced by fibromyalgia patients. One study of 120 women with fibromyalgia saw a decrease in the number of tender/pain points throughout the body and improvement in quality of life during one month after their RIT, compared to another currently used treatment known as repetitive transcranial magnetic stimulation.17 However, more research needs to be done to understand the complexities and mechanism behind why these injections may work for some individuals and why the research has been inconclusive. Additionally, most RIT is not covered by insurance because it is not FDA approved. 18

There are other non-pharmacological therapies that can improve the symptoms of fibromyalgia, including physical therapy, massage therapy, and psychotherapy for mental health issues. Through physical therapy that focused on aerobic exercises, flexibility exercises, and muscle strength training, fibromyalgia patients have reported  improvements in their quality of life and reducing pain.19  However, the benefits from PT tend to vary for a variety of reasons, such as how consistently a patient follows physical therapy exercises at-home . Physical therapy typically tends to be covered by insurance plans.

Massage therapy has been suggested to reduce pain along with anxiety and depression, and is sometimes covered by insurance.21  Massage therapy was more helpful in three of four studies comparing it to relaxation, electrical stimulation (TENS), or no treatment.20 

Being diagnosed with fibromyalgia may be overwhelming or increase someone’s anxiety or depression, which is why psychotherapy may be beneficial. Counseling may assist with learning how to cope with this new illness and the stress that accompanies these new changes.22 Treatment options include talk therapy, including cognitive behavioral therapy (CBT); mindfulness/mediation; and support groups where patients discuss the struggles of their fibromyalgia. For example, a systematic review that included 740 individuals with fibromyalgia   reported improvement in sleep quality, depression, anxiety, and pain for individuals using CBT compared to other non-pharmacological treatments.23 Meditation using mindfulness reduced pain in one study and the Chinese qigong method of breathing exercises reduced pain in two of three studies.20

Acupuncture and spa bathing treatments have been found to be useful in several studies. Acupuncture  involves placing many very thin needles into various pressure points on the body. One systematic review, which included individuals from randomized control trials and controlled clinical trials, found that of the 600+ fibromyalgia patients studied for the effects of acupuncture, many found a “decrease in symptomology” including pain reduction.19 The researchers concluded that acupuncture may need to be done once or twice weekly on a regular basis to get any benefit from the treatments, and even then, it does not work for everyone. Research has shown that spa bathing treatments may reduce pain, using hot or cold water containing minerals such as salt or magnesium.24 This practice, known as balneotherapy, has been around for centuries and used by many civilizations to help assist with skin and inflammatory diseases. In addition, six small studies (less than 50 patients each) evaluated balneotherapy adding an electric current in the water; four of these studies reported a reduction in pain. 19

 

Several methods can be used in conjunction with one another to provide some relief to fibromyalgia patients. However, what works for some patients may not work for others.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

 

Resources:

  1. Centers for Disease Control and Prevention. Fibromyalgia. Cdc.gov. https://www.cdc.gov/arthritis/basics/fibromyalgia.htm. Updated January 6, 2020
  2. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Fibromyalgia. Niams.nih.gov. https://www.niams.nih.gov/health-topics/fibromyalgia#:~:text=Fibromyalgia%20is%20a%20chronic%20(long,a%20heightened%20sensitivity%20to%20pain. Updated July, 2021.
  3. Mayo Clinic. Fibromyalgia. Mayoclinic.org. https://www.mayoclinic.org/diseases-conditions/fibromyalgia/symptoms-causes/syc-20354780.
  4. Wolfe F, Clauw DJ, Fitzcharles M-A, et.al. “The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity.” Arthritis Care and Research 2010; 62(5): 600-610.
  5. Bhargava J, Hurley JA. Fibromyalgia. [Updated 2022 Oct 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK540974/
  6. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Fibromyalgia. Niams.nih.gov. https://www.niams.nih.gov/health-topics/fibromyalgia#:~:text=Fibromyalgia%20is%20a%20chronic%20(long,a%20heightened%20sensitivity%20to%20pain. Updated Jun 2021.
  7. Wierwille L. “Fibromyalgia: Diagnosing and managing a complex syndrome.” Journal of the American Academy of Nurse Practitioners 2012; 24: 184-192.
  8. Homann D, Stefanello JMF, Goes SM, et.al. “Stress Perception and Depressive Symptoms: Functionality and Impact on the Quality of Life of Women with Fibromyalgia.” Revista Brasileira de Reumatologia 2012 Jun; 52(3): 324-330.
  9. Marcus DA. “Fibromyalgia: Diagnosis and Treatment Options.” Gender Medicine 2009; 6: 139-151.
  10. Hauser W, Wolfe F, Tolle T, et.al. “The role of antidepressants in the management of fibromyalgia syndrome: a systematic review and meta-analysis.” CNS Drugs 2012 April 1; 26(4):297-307.
  11. Keller, A, Miller, E, and Ali, A. Cymbalta Side Effects and Withdrawal Symptoms. drugwatch.com. https://www.drugwatch.com/cymbalta/side-effects/. Updated April 27, 2022.
  12. Smith MT, Moore BJ. “Pregabalin for the treatment of fibromyalgia.” Expert Opinion on Pharmacotherapy 2012; 13(10):1527-1533.
  13. Barbehenn E, Wolfe S. “Petition to Ban Fibromyalgia Drug Milnacipran (Savella).”Citizen.org. Public Citizen, 20 Jan. 2010. Web. 27 June 2012.
  14. Hussien et al. Comparison of Amitriptyline and US Food and Drug Administration- Approved Treatments for Fibromyalgia: A systematic review and network meta-analysis. JAMA Network Open. 2022; 5(5):e2212939. doi:10.1001/jamanetworkopen.2022.12939
  15. University of Maryland Medical Center. Regenerative Medicine. Umms.org. https://www.umms.org/ummc/health-services/orthopedics/services/sports-medicine/regenerative-medicine
  16. Univeristy of Pittsburg: School of Health Sciences. Regenative Injection Therapy. Upmc.com https://www.upmc.com/services/rehab/physical-medicine-rehab/treatments/regenerative-injection-therapy#:~:text=Regenerative%20injection%20therapy%2C%20or%20treatment,into%20the%20affected%20muscle%20tissue.
  17. Abd Elghany, S. E., et al. Regenerative injection therapy and repetitive transcranial magnetic stimulation in primary fibromyalgia treatment: A comparative study. Journal of back and musculoskeletal rehabilitation. 2019; 32(1), 55–62. https://doi.org/10.3233/BMR-181127
  18. Cleveland Clinic. Prolotherapy. my.clevelandclinic.org. https://my.clevelandclinic.org/health/treatments/22426-prolotherapy#:~:text=Prolotherapy%20is%20an%20injection%20treatment,found%20no%20scientifically%2Dprovable%20benefits.  Updated Feb 14, 2022.
  19. Araújo FM, DeSantana JM. Physical therapy modalities for treating fibromyalgia. F1000Res. 2019;8:F1000 Faculty Rev-2030. Published Nov 29, 2019. doi:10.12688/f1000research.17176.1
  20. Porter NS, Jason LA. Boulton A, et.al. “Alternative Medical Interventions Used in the Treatment and Management of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome and Fibromyalgia.” The Journal of Alternative and Complementary Medicine 2010; 16(3): 235-249.
  21. Li YH, Wang FY, Feng CQ, Yang XF, Sun YH. Massage therapy for fibromyalgia: a systematic review and meta-analysis of randomized controlled trials. PLoS One. 2014;9(2):e89304. doi:10.1371/journal.pone.0089304
  22. National Health Services. Fibromyalgia- Self-help. Nhs.uk. https://www.nhs.uk/conditions/fibromyalgia/self-help/ Updated Oct 10, 2022.
  23. Climent-Sanz, et al. Cognitive behavioral therapy for insomnia (CBT-i) in patients with fibromyalgia: a systematic review and meta-analysis. Disability and Rehabilitation. 2021; 44 (20): 5770-5783. https://doi.org/10.1080/09638288.2021.1954706
  24. Science Direct. Balneotherapy. https://www.sciencedirect.com/topics/medicine-and-dentistry/balneotherapy