Fibromyalgia

What fibromyalgia is

Fibromyalgia is a disorder of pain processing. In people with fibromyalgia, the brain and spinal cord amplify signals from the body, so normal pressure, movement or temperature feel painful (allodynia) and painful stimuli feel more intense than expected (hyperalgesia). This is called central sensitization, and the condition is now grouped with similar disorders as nociplastic pain.

Brain imaging studies show differences in how pain-related areas respond, and levels of nerve-signaling chemicals such as substance P are altered. Some people also have changes in small nerve fibers in the skin. None of this causes visible damage on X-rays or routine blood tests, which is why fibromyalgia was historically misunderstood. It is a real condition, recognized by the American College of Rheumatology and the World Health Organization.

Fibromyalgia symptoms

Pain

• Aching, burning or throbbing pain on both sides of the body, above and below the waist, and in the neck, back or chest wall
• Tenderness to touch or pressure
• Pain that moves around and varies from day to day
• Stiffness, especially in the morning
• Sensitivity to cold, noise, bright light or smells

Fatigue and sleep

• Exhaustion that rest does not fix
• Waking up feeling unrefreshed even after a full night
• Frequent waking and light sleep; restless legs and sleep apnea are more common

Fibro fog

• Trouble concentrating, finding words and remembering recent events
• Feeling mentally slow, especially on bad days

Other common symptoms

• Headaches and migraine
• Tingling or numbness in the hands and feet without nerve damage on tests
• Irritable bowel syndrome: bloating, abdominal pain, diarrhea or constipation
• Bladder pain and urgency, painful periods, jaw pain (TMJ disorder)
• Anxiety and depression, which are both a consequence of chronic pain and can worsen it

Fibromyalgia flares

Symptoms wax and wane. Common flare triggers are physical overexertion, emotional stress, poor sleep, illness or surgery, weather changes and long periods of inactivity. A flare can last days to weeks.

What causes fibromyalgia?

The exact cause is unknown. Several factors combine:

• Genetics: fibromyalgia runs in families.
• Sex: women are diagnosed more often, though with the newer criteria the difference is smaller than once thought.
• Triggering events: a physical injury, a car accident, a viral infection, surgery, or major emotional stress often comes before symptoms.
• Other painful conditions: people with rheumatoid arthritis, lupus, osteoarthritis or ankylosing spondylitis are more likely to develop fibromyalgia as well.
• Psychological factors: childhood adversity, PTSD and depression increase the risk.
• Poor sleep and inactivity, which both increase pain sensitivity.

How fibromyalgia is diagnosed

There is no single test. A doctor diagnoses fibromyalgia from your symptoms and examination, usually using the American College of Rheumatology (2016) criteria:

1. Widespread pain in at least 4 of 5 body regions
2. Symptoms present at a similar level for at least 3 months
3. A high score on the Widespread Pain Index and Symptom Severity Scale, which counts painful areas and rates fatigue, unrefreshing sleep and cognitive problems

The old "18 tender points" test is no longer required.

Blood tests are used to rule out conditions that can look similar:

A diagnosis of fibromyalgia does not exclude another condition. Many people have both.

Fibromyalgia treatment

Guidelines from EULAR and others agree: start with education and non-drug treatment, and add medicine for those who need it.

Exercise: the most effective single treatment

• Aerobic exercise such as walking, cycling, swimming or water aerobics, built up slowly. Start with 5 to 10 minutes a day and add a few minutes each week, aiming eventually for about 150 minutes a week.
• Strength training with light weights or bands, 2 to 3 times a week.
• Tai chi, yoga and qigong improve pain, sleep and mood in trials.
• Expect a temporary increase in pain when starting. Going slowly prevents "boom and bust" cycles.

Sleep

Keep regular sleep and wake times, avoid naps longer than 30 minutes, cut caffeine after midday, and treat sleep apnea or restless legs if present.

Psychological therapies

• Cognitive behavioral therapy (CBT) helps with pain coping, sleep and mood.
• Acceptance and commitment therapy and mindfulness-based programs reduce the impact of pain.
• Pacing: planning activity in manageable chunks with rest breaks.

Medicines

• Duloxetine or milnacipran (SNRI antidepressants): reduce pain and fatigue in some people, even without depression.
• Pregabalin or gabapentin: can improve pain and sleep; cause drowsiness and dizziness.
• Low-dose amitriptyline at night: helps sleep and pain.
• Acetaminophen (paracetamol) and NSAIDs have limited benefit for fibromyalgia pain itself but can help coexisting arthritis. Follow the label dose; NSAIDs can cause stomach and kidney problems.
• Opioids, including tramadol in most cases, are not recommended: evidence of benefit is poor and risks are significant.

Medicines usually provide a modest improvement in 30% to 50% of people. They work best combined with exercise.

Other approaches

Heat, warm baths and massage give short-term relief. Acupuncture and hydrotherapy help some people. Weight loss can reduce pain in people with obesity.

Living with fibromyalgia

Fibromyalgia does not damage joints, muscles or organs and does not shorten life. It does affect work, relationships and daily life, and symptoms usually persist long term with good and bad periods. People who stay active, keep a consistent sleep routine and learn self-management skills tend to do best. Workplace adjustments, such as flexible hours or regular breaks, can help people remain in work.

Frequently asked questions

What are the first signs of fibromyalgia?

Common early signs are aching and tenderness that spread across the body, fatigue that rest does not relieve, waking unrefreshed, and difficulty concentrating. Symptoms often begin after an illness, injury or stressful period and build over months.

Is fibromyalgia an autoimmune disease?

No. Fibromyalgia is not autoimmune and does not cause inflammation or tissue damage. It is a pain processing disorder. However, people with autoimmune conditions such as lupus and rheumatoid arthritis are more likely to develop fibromyalgia as well.

What does a fibromyalgia flare feel like?

A flare is a period of increased pain, stiffness, fatigue and brain fog that can last days or weeks. Many people describe feeling flu-like, with burning or aching all over. Triggers include overexertion, stress, poor sleep, infection and weather changes.

Can fibromyalgia go away?

Fibromyalgia is usually long-term, but symptoms vary and can improve a great deal with exercise, good sleep and coping skills. Some people have long periods with few symptoms. Starting treatment early and staying active gives the best chance of improvement.

Why is fibromyalgia more common in women?

Women are diagnosed more often, possibly because of differences in pain processing, hormones and genetics. Older criteria based on tender points also favored women. With current criteria, the gap is smaller, and men with fibromyalgia may be underdiagnosed.

What is the best exercise for fibromyalgia?

Low-impact aerobic exercise, such as walking, swimming, water aerobics or cycling, has the strongest evidence. Start very gently, for 5 to 10 minutes, and increase slowly over weeks. Adding light strength training and tai chi or yoga can bring further benefit.