Fibromyalgia management
Fibromyalgia should be managed using a graduated approach that combines non-pharmacologic and pharmacologic modalities tailored to pain intensity, function, psychosocial comorbidity (eg, depression), fatigue, sleep disturbance, and patient preferences. [1] Initial management should focus on non-pharmacologic therapies. [1] Pharmacologic therapy is used when non-pharmacologic therapy provides inadequate effect. [1]
Non-pharmacologic therapy
Non-pharmacologic therapy is recommended as first-line management. [1]
Exercise and physical activity interventions
Aerobic exercise and strengthening exercise are recommended. [1] Supervised group exercise and long-term encouragement of physical activity are recommended for chronic primary pain. [2]
Psychological and educational interventions
Cognitive behavioral therapy is recommended. [1] Acceptance and commitment therapy or cognitive behavioral therapy is recommended for chronic primary pain. [2]
Multicomponent and physical therapies
Multicomponent therapies are recommended. [1] Multicomponent care is recommended as part of chronic primary pain pain management programs. [2] Defined physical therapies such as acupuncture or hydrotherapy are recommended. [1]
Mind-body interventions
Meditative movement therapies such as qigong, yoga, and tai chi are recommended with weaker strength. [1]
Pharmacologic therapy selection
Pharmacologic management should be tailored to symptom profile and comorbidities, using shared decision-making. [1]
First-line pharmacologic options
Low-dose amitriptyline is recommended. [1] Duloxetine or milnacipran is recommended. [1] Pregabalin is recommended. [1] Tramadol is recommended with weaker strength. [1] Cyclobenzaprine is recommended with weaker strength. [1]
Pharmacologic options to avoid or restrict
Antidepressants are listed as a chronic primary pain option, but initiation of other medication classes is discouraged in chronic primary pain, including gabapentinoids (including pregabalin and gabapentin) unless part of a clinical trial for complex regional pain syndrome. [2] Non-steroidal anti-inflammatory drugs are discouraged for chronic primary pain. [2] Opioids are discouraged for chronic primary pain. [2]
Ongoing reassessment and adjustment
Reassessment and adjustment of the care and support plan are recommended when symptoms change or flare. [2]