Fibromyalgia
Summary
Fibromyalgia is a chronic condition characterised by widespread musculoskeletal pain, fatigue, sleep disturbance, and cognitive dysfunction ("fibro fog"). It is a diagnosis of exclusion — investigations are normal. The pathophysiology involves central sensitisation with amplified pain processing in the CNS. Diagnosis is clinical, based on the widespread pain index (WPI) and symptom severity scale (SSS). Management is multidisciplinary: patient education, graded aerobic exercise, and pharmacological options including amitriptyline, duloxetine, and pregabalin. Cognitive behavioural therapy (CBT) is also effective. The condition is chronic but not progressive or life-threatening.
Key Facts
- Prevalence: 2-8% of population; Female:Male = 2:1
- Features: Widespread pain, Fatigue, Sleep disturbance, Cognitive symptoms
- Diagnosis: Clinical; Normal investigations
- Not inflammatory: Normal CRP, ESR
- Comorbidities: Depression, Anxiety, IBS, Chronic fatigue syndrome
- Treatment: Exercise (first-line); Amitriptyline; Duloxetine; Pregabalin; CBT
Clinical Pearls
"Normal Bloods + Widespread Pain = Fibromyalgia": If inflammatory markers are normal and there's no objective inflammation, think fibromyalgia. Don't over-investigate.
"Central Sensitisation": Fibromyalgia is not a peripheral problem — it's central pain amplification. The pain is real but generated by abnormal CNS processing.
"Exercise Is First-Line": Graded aerobic exercise is the most evidence-based intervention. Start low, go slow.
"Amitriptyline Helps Sleep and Pain": Low-dose amitriptyline (10-25 mg at night) improves sleep and reduces pain through central mechanisms.
"Address the Comorbidities": Depression, anxiety, and sleep disorders are common. Treating these improves overall outcomes.
Why This Matters Clinically
Fibromyalgia is common and often poorly managed. Patients frequently feel dismissed. Acknowledging the reality of their symptoms, providing education, and using evidence-based treatments improves quality of life.[1,2]
Incidence & Prevalence
| Parameter | Data |
|---|---|
| Prevalence | 2-8% of population |
| Sex | Female:Male = 2-3:1 |
| Age | Peak 30-50 years |
Risk Factors
| Factor | Notes |
|---|---|
| Female sex | Higher prevalence |
| Family history | Genetic component |
| Physical trauma | May trigger onset |
| Psychological stress | May trigger or worsen |
| Other chronic pain conditions | IBS, TMJ, Chronic headache |
Central Sensitisation
| Feature | Details |
|---|---|
| Abnormal pain processing | Amplification of pain signals in CNS |
| Reduced descending inhibition | Impaired pain modulation |
| Neurotransmitter abnormalities | Substance P increased; Serotonin, Norepinephrine decreased |
| Functional MRI | Increased activation of pain-processing regions |
This Is NOT an Inflammatory Condition
- No joint swelling
- No synovitis
- Normal CRP, ESR
- Normal imaging
- Autoantibodies negative
Core Symptoms
| Symptom | Notes |
|---|---|
| Widespread pain | Axial + Upper and lower body; Both sides; >3 months |
| Fatigue | Persistent, unrefreshing |
| Sleep disturbance | Non-restorative sleep; Waking unrefreshed |
| Cognitive symptoms | "Fibro fog" — Poor concentration, memory |
Associated Symptoms
| Symptom | Prevalence |
|---|---|
| Headaches | Common |
| IBS-like symptoms | 30-70% |
| Paraesthesia | Without objective neuropathy |
| Sensitivity | To light, noise, temperature |
| Depression/Anxiety | 30-50% |
Signs
| Sign | Finding |
|---|---|
| Tender points | Multiple areas of tenderness (no longer required for diagnosis) |
| No joint swelling | Key distinguishing feature from inflammatory arthritis |
| No synovitis | No heat, effusion |
| Normal neurological exam | Important to exclude neuropathy |
Red Flags
[!CAUTION] Consider alternative diagnosis if:
- Objective joint swelling or synovitis
- Morning stiffness >1 hour (inflammatory)
- Weight loss
- Focal neurological signs
- New onset in elderly
Musculoskeletal
| Finding | Notes |
|---|---|
| Widespread tenderness | Multiple sites; Not localised to joints |
| No synovitis | No swelling, warmth, effusion |
| Normal range of motion |
Neurological
- Normal power, reflexes, sensation
- Excludes peripheral neuropathy
Purpose
Investigations are to exclude other diagnoses, not to confirm fibromyalgia.
| Investigation | Purpose | Expected Finding |
|---|---|---|
| FBC | Anaemia, infection | Normal |
| CRP / ESR | Inflammation | Normal |
| TFTs | Hypothyroidism | Normal |
| Vitamin D | Deficiency causes pain | Check and correct |
| Rheumatoid factor, Anti-CCP | RA | Negative |
| ANA | CTD | Usually negative |
Diagnostic Criteria (2016 ACR)
| Component | Criteria |
|---|---|
| Widespread Pain Index (WPI) | Score ≥7 |
| Symptom Severity Scale (SSS) | Score ≥5 |
| OR | WPI 4-6 AND SSS ≥9 |
| Duration | >3 months |
| No other explanation | After clinical assessment |
Management Algorithm
FIBROMYALGIA MANAGEMENT
↓
┌───────────────────────────────────────────────────────────┐
│ EDUCATION & REASSURANCE │
├───────────────────────────────────────────────────────────┤
│ ➤ Validate the patient's pain — it is real │
│ ➤ Explain central sensitisation │
│ ➤ Set realistic expectations — chronic but manageable │
│ ➤ Avoid over-investigation │
└───────────────────────────────────────────────────────────┘
↓
┌───────────────────────────────────────────────────────────┐
│ NON-PHARMACOLOGICAL (FIRST-LINE) │
├───────────────────────────────────────────────────────────┤
│ ➤ Graded aerobic exercise (walking, swimming, cycling) │
│ • Start low, increase gradually │
│ • Most evidence-based intervention │
│ ➤ CBT (Cognitive Behavioural Therapy) │
│ ➤ Sleep hygiene │
│ ➤ Stress management │
│ ➤ Hydrotherapy │
└───────────────────────────────────────────────────────────┘
↓
┌───────────────────────────────────────────────────────────┐
│ PHARMACOLOGICAL OPTIONS │
├───────────────────────────────────────────────────────────┤
│ FIRST-LINE: │
│ ➤ Amitriptyline 10-75 mg at night │
│ • Helps pain and sleep │
│ │
│ ➤ Duloxetine 30-60 mg daily │
│ • SNRI; Good if coexisting depression │
│ │
│ ➤ Pregabalin 75-300 mg BD │
│ • Evidence for pain reduction; Also helps anxiety │
│ │
│ SECOND-LINE: │
│ ➤ Gabapentin │
│ ➤ Tramadol (short-term only; avoid long-term opioids) │
│ │
│ AVOID: │
│ ➤ Strong opioids — not effective; Risk of dependency │
│ ➤ NSAIDs — not effective (no inflammation) │
│ ➤ Corticosteroids — no role │
└───────────────────────────────────────────────────────────┘
↓
┌───────────────────────────────────────────────────────────┐
│ TREAT COMORBIDITIES │
├───────────────────────────────────────────────────────────┤
│ ➤ Depression: SSRIs/SNRIs │
│ ➤ Anxiety: CBT, SSRIs, Pregabalin │
│ ➤ Sleep disorder: Sleep hygiene; Low-dose amitriptyline │
│ ➤ IBS: Dietary modification │
└───────────────────────────────────────────────────────────┘
| Complication | Notes |
|---|---|
| Disability | Reduced work capacity; QoL impact |
| Depression/Anxiety | Common; Worsens pain perception |
| Medication side effects | Weight gain; Drowsiness |
| Opioid dependence | If inappropriately prescribed |
| Factor | Outcome |
|---|---|
| Chronic | Lifelong condition; Not progressive |
| Not life-threatening | Does not affect life expectancy |
| Variable | Some improve; Some remain symptomatic |
| Better outcomes | With exercise adherence and addressing comorbidities |
Key Guidelines
| Guideline | Organisation | Year | Key Points |
|---|---|---|---|
| EULAR Fibromyalgia Recommendations | EULAR | 2017 | Exercise first-line; Individualised pharmacotherapy |
What is fibromyalgia?
Fibromyalgia is a long-term condition that causes widespread pain throughout the body. It's often accompanied by tiredness, sleep problems, and difficulty concentrating.
What causes it?
The exact cause is unknown, but it's thought to involve changes in how the brain and spinal cord process pain signals, making them more sensitive.
What are the symptoms?
- Pain all over the body
- Feeling tired all the time
- Poor sleep
- "Brain fog" — trouble thinking clearly
- Headaches, gut problems
How is it treated?
- Exercise: Regular gentle exercise (walking, swimming) is the most helpful treatment
- Medications: Tablets like amitriptyline, duloxetine, or pregabalin can help
- Talking therapies: CBT can help manage pain
- Lifestyle: Good sleep habits, stress management
Is it serious?
Fibromyalgia is not dangerous and doesn't damage your joints or muscles. It can affect daily life, but many people learn to manage it well.
- Macfarlane GJ, Kronisch C, Dean LE, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis. 2017;76(2):318-328. PMID: 27377815
High-Yield Exam Topics
| Topic | Key Points |
|---|---|
| Diagnosis | Clinical; WPI + SSS; Normal investigations |
| Not inflammatory | Normal CRP, ESR; No synovitis |
| First-line treatment | Graded aerobic exercise |
| Pharmacological | Amitriptyline, Duloxetine, Pregabalin |
| Avoid | Strong opioids; NSAIDs; Steroids |
| Central sensitisation | Key pathophysiology |
Sample Viva Question
Q: A patient presents with widespread pain and fatigue. Investigations are normal. How would you diagnose and manage fibromyalgia?
Model Answer: I would diagnose fibromyalgia clinically using the 2016 ACR criteria: Widespread Pain Index ≥7 and Symptom Severity Scale ≥5, with symptoms present for >3 months and no other explanation. Key investigations to exclude differentials: FBC, CRP, ESR, TFTs, Vitamin D — all normal in fibromyalgia.
Management:
- Education: Validate symptoms; Explain central sensitisation
- Non-pharmacological (first-line): Graded aerobic exercise; CBT
- Pharmacological: Amitriptyline 10-25 mg at night (helps sleep and pain); OR Duloxetine if depression coexists; OR Pregabalin for pain and anxiety
- Avoid: Strong opioids (ineffective and harmful); NSAIDs (no inflammation)
Address comorbidities: depression, anxiety, sleep disorder.
Last Reviewed: 2025-12-24 | MedVellum Editorial Team