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FIBROMYALGIA OVERVIEW — Fibromyalgia is one of a group of chronic pain disorders that affect connective tissues, including the muscles, ligaments (the tough bands of tissue that bind together the ends of bones), and tendons (which attach muscles to bones). It is a chronic condition that causes widespread muscle pain (known as "myalgia") and extreme tenderness in many areas of the body. Many patients also experience fatigue, sleep disturbances, headaches, and mood disturbances such as depression and anxiety. Despite ongoing research, the cause, diagnosis, and optimal treatment of fibromyalgia are not clear.
In the United States, fibromyalgia affects about 2 percent of people by age 20, which increases to approximately 8 percent of people by age 70; it is the most common cause of generalized musculoskeletal pain in women between 20 and 55 years. It is more common in women than men.
FIBROMYALGIA CAUSES — The cause of fibromyalgia is unknown. Various physical or emotional factors (such as infection, injury, or stress) may play a role in triggering symptoms, although many patients report a lifelong history of chronic pain.
In people with fibromyalgia, the muscles and tendons are excessively irritated by various painful stimuli. This is thought to be due to a heightened perception of pain, a phenomenon called "central sensitization." Other conditions may also develop as a result of central sensitization, including irritable bowel syndrome (IBS); chronic fatigue syndrome (CFS), also known as myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS); chronic headaches; chronic pelvic and bladder pain; and chronic jaw and facial pain.
There is no generally agreed-upon explanation for how or why central sensitization develops in some people. The most plausible theory suggests that there is a genetic component, meaning that some people are predisposed to having a heightened sense of pain. People with a parent or sibling with fibromyalgia have a higher chance of developing it themselves. In some cases, various stressors, including infection (eg, Lyme disease or viral illness), diseases that involve joint inflammation (eg, rheumatoid arthritis or systemic lupus erythematosus), physical or emotional trauma, or sleep disturbances appear to trigger the development of fibromyalgia.
Brain imaging studies in people with fibromyalgia and related chronic pain disorders have shown changes in brain function and connections between different parts of the brain. As research continues, the factors that lead to chronic pain in fibromyalgia will be better understood, hopefully allowing for the development of better treatments.
FIBROMYALGIA SYMPTOMS
Muscle and soft tissue pain — The primary symptom of fibromyalgia is widespread (or "diffuse"), chronic, and persistent pain. Although the pain is felt in muscles and soft tissues, there are no visible abnormalities in these areas. The pain may be described as a deep muscular aching, soreness, stiffness, burning, or throbbing. Patients may also feel numbness, tingling, or unusual "crawling" sensations in the arms and legs. Although some degree of muscle pain is always present, it varies in intensity and is aggravated by certain conditions, such as anxiety or stress, poor sleep, exertion, or exposure to cold or damp conditions. People often describe their muscle symptoms as feeling like they always have the flu.
The pain may be confined to specific areas, often the neck or shoulders, early in the course of the disease. Multiple regions are eventually involved, with most patients experiencing pain in the neck, middle and lower back, arms and legs, and chest wall. Areas called "tender points" can feel painful with even mild to moderate pressure. Many patients with fibromyalgia feel that their joints are swollen, although there is no visible inflammation of the joints (as would be found in forms of arthritis).
Other pain symptoms — Patients with fibromyalgia are often affected by other pain-related symptoms, including:
●Repeated headaches, including migraines (see "Patient education: Headache causes and diagnosis in adults (Beyond the Basics)")
●Symptoms of irritable bowel syndrome (IBS), including frequent abdominal pain and episodes of diarrhea, constipation, or both (see "Patient education: Irritable bowel syndrome (Beyond the Basics)")
●Interstitial cystitis/painful bladder syndrome, in which bladder pain and urinary urgency and frequency are typically present without an infection (see "Patient education: Diagnosis of interstitial cystitis/bladder pain syndrome (Beyond the Basics)"); and chronic, unexplained pelvic pain
●Temporomandibular joint (TMJ) syndrome, which can involve limited jaw movement; clicking, snapping, or popping sounds while opening or closing the mouth; pain within facial or jaw muscles in or around the ear; or headaches
Fatigue and sleep disturbances — Persistent fatigue occurs in more than 90 percent of people with fibromyalgia. Most people complain of unusually light, unrefreshing, or nonrestorative sleep. Difficulties falling asleep, awakening repeatedly during the night, and feeling exhausted upon awakening are also common problems.
People with fibromyalgia may also have sleep apnea (when the person stops breathing for a few moments while sleeping) or restless legs syndrome (when there is an uncontrollable urge to move the legs). Like some painful conditions, these sleep problems might also be triggers of fibromyalgia. If you have one or both of these problems, your doctor will likely recommend a formal sleep evaluation to confirm the diagnosis. (See "Patient education: Sleep apnea in adults (Beyond the Basics)".)
There appears to be a close relationship between fibromyalgia and chronic fatigue syndrome (CFS), also known as myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), which is primarily characterized by chronic, debilitating fatigue. Most patients with CFS meet the "tender point" criteria for fibromyalgia (meaning that they have pain in many of the areas commonly affected in people with fibromyalgia), and up to 70 percent of those with fibromyalgia meet the criteria for CFS (table 1). A better understanding of both conditions is needed to clarify how they may be related. (See "Patient education: Myalgic encephalomyelitis/chronic fatigue syndrome (Beyond the Basics)".)
Depression and anxiety — Many people with fibromyalgia also have depression and/or anxiety at the time of diagnosis, or develop one or both later in life. However, this is true of most chronic pain conditions, and fibromyalgia is not simply a physical manifestation of depression. (See "Patient education: Depression in adults (Beyond the Basics)".)
FIBROMYALGIA DIAGNOSIS — There are no specific laboratory or imaging tests used to diagnose fibromyalgia. Thus, the diagnosis is typically based upon a thorough patient history, a complete physical examination, and a limited number of blood tests, which are used to exclude conditions with similar symptoms.
Different diagnostic guidelines have been used, and different health care providers may vary in their process, but all approaches involve evaluating your pain, fatigue, and other symptoms that may be related.
●The American College of Rheumatology (ACR) developed classification criteria for fibromyalgia in 1990 that have often been used to help make the diagnosis. According to these criteria, a person can be diagnosed with fibromyalgia if he or she has widespread musculoskeletal pain and excess tenderness in at least 11 of 18 specific "tender points" (based on clinician examination).
●The ACR released updated diagnostic criteria in 2010. These criteria do not require a tender point examination but use a numerical scoring system based on how widespread and severe a person describes their pain to be. They also consider other symptoms such as fatigue, cognitive problems (eg, trouble thinking clearly), and other pain-related issues such as headache or digestive problems.
●Diagnostic criteria proposed by the Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION)-American Pain Society (APS) Pain Taxonomy (AAAPT) include multisite pain (defined as at least six out of nine possible sites) and moderate to severe sleep problems or fatigue, present for at least three months.
If you have symptoms of fibromyalgia, your doctor should obtain a medical history and do a physical exam to rule out arthritis, other connective tissue problems, neurologic conditions, and other disorders that may be causing your symptoms (see 'Conditions that can be similar to fibromyalgia' below). Routine laboratory tests may be recommended to help exclude certain conditions, such as inflammatory arthritis, thyroid disease, and disorders of the muscles. Results of these tests are normal in most people with fibromyalgia.
Because people with fibromyalgia frequently have symptoms besides muscle pain, including persistent fatigue, headache, additional pain symptoms, and sleep and mood disturbances, your doctor may also suggest the following:
●Informal or formal evaluation of mood problems such as depression or anxiety – If you have symptoms of depression or anxiety, you may be referred to a mental health specialist for further evaluation or treatment.
●A thorough sleep history – If your sleep history suggests a sleep disturbance such as restless legs syndrome or sleep apnea, you will be referred to a sleep specialist for additional evaluation and treatment. (See "Patient education: Sleep apnea in adults (Beyond the Basics)".)
Conditions that can be similar to fibromyalgia — The process of determining whether a person's signs and symptoms are related to fibromyalgia or to another condition can be lengthy and complex in some cases. Many illnesses can cause generalized muscle aches, fatigue, and other common symptoms of fibromyalgia.
It is important to note that fibromyalgia can occur in people with rheumatoid arthritis, systemic lupus erythematosus, osteoarthritis, and other conditions (see below). If this is the case, it may be difficult to determine whether your symptoms of chronic pain and fatigue are caused by fibromyalgia or your other condition. Often this will require consultation with a rheumatologist.
The following is a sample of disorders that your doctor may consider during the diagnostic process:
●Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) – RA is a chronic disease that causes inflammation of joints, resulting in pain, swelling, and potential deformity of the affected joints. SLE is also a chronic, inflammatory disorder of connective tissue that can affect multiple organs.
Although both RA and SLE share many symptoms with fibromyalgia, they have other features that are not usually seen in people with fibromyalgia, including inflammation of the synovial membranes (connective tissue that lines the spaces between bones and joints). (See "Patient education: Systemic lupus erythematosus (Beyond the Basics)" and "Patient education: Rheumatoid arthritis symptoms and diagnosis (Beyond the Basics)".)
●Osteoarthritis (OA) – OA causes stiffness, tenderness, pain, and potential deformity of affected joints, and it most commonly occurs in older individuals. Doctors can differentiate OA from fibromyalgia based upon a person's medical history, physical examination, and x-ray results (in OA, x-rays can show degenerative joint changes that are not present in fibromyalgia). (See "Patient education: Osteoarthritis symptoms and diagnosis (Beyond the Basics)".)
●Ankylosing spondylitis (AS) – AS is a chronic, progressive, inflammatory disease involving joints of the spine. This condition leads to stiffness, pain, and decreased movement of the spine. AS also causes characteristic findings that can be seen on x-ray, which are absent in people with fibromyalgia. By contrast, spinal motion and x-rays are usually normal in people with fibromyalgia. (See "Patient education: Axial spondyloarthritis, including ankylosing spondylitis (Beyond the Basics)".)
●Polymyalgia rheumatica (PMR) – PMR is a chronic, inflammatory condition that causes stiffness and pain in the shoulders, hips, or other areas of the body. The disorder, which primarily affects people older than 50, is frequently associated with inflammation of certain large arteries. PMR is differentiated from fibromyalgia based upon a person's medical history, physical examination, and blood tests. (See "Patient education: Polymyalgia rheumatica and giant cell arteritis (Beyond the Basics)".)
●Hypothyroidism and other endocrine disorders – Decreased activity of the thyroid gland, known as hypothyroidism, can cause fatigue, sleep disturbances, and generalized aches, similar to those in fibromyalgia. Blood tests to measure thyroid function are routinely conducted to help exclude hypothyroidism. Other endocrine disorders, including increased activity of the parathyroid glands (hyperparathyroidism), can also cause symptoms similar to fibromyalgia. (See "Patient education: Hypothyroidism (underactive thyroid) (Beyond the Basics)" and "Patient education: Primary hyperparathyroidism (Beyond the Basics)".)
●Muscle inflammation (myositis) or muscle disease due to metabolic abnormalities (metabolic myopathy) – These conditions cause muscle fatigue and weakness, but not the widespread pain seen in fibromyalgia. In addition, patients with myositis typically have abnormal levels of muscle enzymes. (See "Patient education: Polymyositis, dermatomyositis, and other forms of idiopathic inflammatory myopathy (Beyond the Basics)".)
●Neurologic disorders – These may include disorders of the brain and spinal cord (central nervous system or CNS) or of nerves outside the CNS (peripheral nervous system). A thorough neurologic examination can assist in differentiating fibromyalgia from neurologic disease. A subset of people with fibromyalgia may have evidence of nerve damage and should be referred to a neurologist.
FIBROMYALGIA AND COVID-19 — Although many chronic medical illnesses may have been exacerbated during the coronavirus disease 2019 (COVID-19) pandemic, patients with pre-existing fibromyalgia may be particularly vulnerable. Stress and social isolation adversely impact mood, including depression, and anxiety, as well as sleep disturbance, which are common symptoms in fibromyalgia.
There is also evidence that the COVID-19 pandemic has precipitated new cases of fibromyalgia. For example, chronic, unexplained widespread pain is common for months after the initial COVID-19 infection, a common symptom in what has been termed long COVID syndrome. Such patients often meet the clinical criteria for fibromyalgia.
FIBROMYALGIA TREATMENT — Ideally, the treatment of fibromyalgia should involve you and your doctor, as well as (in many cases) a physical therapist, mental health expert, and other health care professionals.
It may help to keep the following in mind:
●Fibromyalgia is a real illness, and your pain is not "all in your head."
●Fibromyalgia is not a degenerative or deforming condition, nor does it result in life-threatening complications. However, treatment of chronic pain and fatigue is challenging, and there are no "quick cures."
●Treatments are available. Medications may be helpful in relieving pain, improving your quality of sleep, and improving your mood. Exercise, stretching programs, and other activities are also important in helping to manage symptoms. An approach that involves combining multiple different types of intervention into an organized treatment program is usually best. Being physically active will not cause harm or long-term muscle damage, and it can help improve pain and function.
●Understanding fibromyalgia, and accepting that its cause is not well understood, may help to improve your response to treatment. As an example, some people believe that their illness is due to an undiagnosed or persistent infection; however, there is no evidence that this is true. Learning about fibromyalgia as well as some of the common myths may help you to cope better with your symptoms.
●It is important to try to have realistic expectations about your fibromyalgia and how much it can be managed. Symptoms often increase and decrease over time, but some degree of muscle pain and fatigue generally persist. Nevertheless, most people with fibromyalgia improve, and most people lead full, active lives.
Medications — In addition to exercise and coping techniques to help manage symptoms, many people with fibromyalgia benefit from medication. The medications that have been most effective in relieving symptoms of fibromyalgia in clinical trials are drugs that target chemicals in the brain and spinal cord that are important in processing pain. These include some of the medications usually used to treat depression (antidepressants) and epilepsy (anticonvulsants). By contrast, medications and techniques that work to decrease symptoms of pain locally, such as antiinflammatory drugs and analgesics, are less effective.
The best medication for you will depend on your symptoms, preferences, and cost concerns, as well as which drugs are available in your area. Your doctor can talk to you about options and how to begin medication therapy. In general, medication is usually started at a low dose and then increased slowly as needed.
Antidepressants — There are several different classes of drugs used to treat depression (see "Patient education: Depression treatment options for adults (Beyond the Basics)"). Some of these can be effective in treating fibromyalgia symptoms as well.
●Tricyclic antidepressants (TCAs) – These drugs are often used first in treating fibromyalgia. Examples include amitriptyline and nortriptyline. Cyclobenzaprine, a closely related medication, may help in treating fibromyalgia but is not effective for depression. Taking TCAs before bedtime may promote deeper sleep and may alleviate muscle pain. Lower doses are usually used in fibromyalgia than the doses needed to treat depression, but even when taken at low doses, side effects are common; they may include dry mouth, fluid retention, weight gain, constipation, or difficulty concentrating.
●Dual-reuptake inhibitors – These drugs, also called serotonin-norepinephrine reuptake inhibitors (SNRIs), can help with symptoms of fibromyalgia as well. They include duloxetine and milnacipran. The most common side effects are nausea and dizziness, but these are generally more tolerable if the dose is started at a low level and is increased very slowly.
●Selective serotonin-reuptake inhibitors – Selective serotonin-reuptake inhibitors (SSRIs) such as fluoxetine and paroxetine may also be effective in fibromyalgia. However, they are not as effective for pain reduction as the tricyclic or dual-reuptake medications. SSRIs are not typically used as initial treatment of fibromyalgia, but doctors might try them in some situations. These are a group of antidepressant drugs that work to increase the concentration of serotonin in the brain. Serotonin is a naturally produced chemical that regulates the delivery of messages between nerve cells.
Anticonvulsants — Certain anticonvulsants (drugs used primarily for treating epilepsy) may help to relieve pain and improve sleep. They include pregabalin and gabapentin and are thought to relieve pain by blocking certain chemicals that increase pain transmission. The most common side effects of these drugs include feeling sedated or dizzy, gaining weight, or developing swelling in the lower legs; however, most people tolerate these medications well.
Often, more than one class of these drugs are used together. For example, a low dose of a serotonin-norepinephrine reuptake inhibitor would be taken in the morning and a low dose of a tricyclic antidepressant or another drug would be taken at bedtime.
Other drugs — You may wonder about other medications for treating your symptoms. However, evidence is limited, and it's important to talk with your doctor about your situation and what approach is most likely to help.
Fibromyalgia does not cause tissue inflammation; thus, neither nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen (sample brand names: Advil, Motrin) or naproxen (sample brand name: Aleve) nor glucocorticoids (steroids) are effective in relieving fibromyalgia symptoms. (See "Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)".)
Analgesics (pain-relieving medications) are sometimes added to fibromyalgia medications for people who need additional short-term pain relief. They include acetaminophen (sample brand name: Tylenol) and the prescription medication tramadol (sample brand name: Ultram), which may be used alone or in combination. Tramadol is an opioid, although it is weaker than other opioid drugs and less likely to result in addiction. It may cause dizziness, diarrhea, or sleep disturbances in some people.
There is no evidence that long-term opioids are effective in treating fibromyalgia symptoms, and these drugs come with potentially serious side effects as well as a risk of addiction. Some people with fibromyalgia have reported that cannabis products, particularly cannabidiol (CBD), are helpful; however, this has not been studied sufficiently to confirm benefit and safety of these compounds. The Arthritis Foundation has urged the US Food and Drug Association (FDA) to expedite the study and regulation of cannabis for the treatment of fibromyalgia.
Non-medication treatments
Exercise — Regular exercise, such as walking, swimming, or biking, is helpful in reducing muscle pain and improving muscle strength and fitness in fibromyalgia. If you are beginning an exercise program for the first time, it's best to start slowly and gradually increase your level of activity. Over time, exercise typically improves fibromyalgia symptoms. Muscle strengthening programs also appear to improve pain, decrease the number of tender points, and improve muscle strength.
It can also help to work with a physical therapist to develop an appropriate, individualized exercise program that will be of most benefit to you. Eventually, a good goal is to exercise for at least 30 minutes three times weekly. A separate topic review discusses exercise and arthritis; some of these approaches may also help people with fibromyalgia. (See "Patient education: Arthritis and exercise (Beyond the Basics)".)
Relaxation therapies — In some cases, participating in stress-reduction programs, learning relaxation techniques, or participating in hypnotherapy (hypnosis), biofeedback, or cognitive behavioral therapy (CBT) may help to relieve certain symptoms. Of these approaches, the most is known about CBT.
●CBT is based on the concept that people's perceptions of themselves and of their surroundings affect their emotions and behavior. The goal of CBT is to change the way you think about pain and to deal with illness more positively. CBT has been especially effective when combined with patient education and information, ie, learning about your disease and how to manage it.
●Mind-body stress reduction (MBSR) programs have been effective in fibromyalgia. MBSR may be individual or as part of a group and may involve discussion, meditation, and other techniques, such as hypnosis and biofeedback. During biofeedback, patients use information about typically unconscious bodily functions, such as muscle tension or blood pressure, to help gain conscious control over such functions.
Tai chi and yoga — Some people with fibromyalgia benefit from a traditional Chinese exercise called tai chi (which combines mind-body practice with gentle, flowing movement exercises) or yoga.
Acupuncture — Acupuncture involves inserting hair-thin, metal needles into the skin at specific points on the body. It causes little to no pain. In some cases, a mild electric current is applied to the needle, termed electroacupuncture. Most studies have found acupuncture to be helpful but there has been little difference found between traditional and "sham" acupuncture.
Multidisciplinary therapy — Fibromyalgia typically responds best to an integrated management program, combining medications, exercise, and cognitive approaches. This works best if a team of health care professionals is involved.
LIVING WITH FIBROMYALGIA — While fibromyalgia is not a life-threatening disorder, many people worry that their symptoms represent the "early stages" of a more serious condition, such as systemic lupus erythematosus. However, long-term studies do not indicate that people with fibromyalgia have an increased risk of developing other rheumatic diseases or neurologic conditions.
Most people with fibromyalgia continue to have chronic pain and fatigue throughout their lives. However, most people are able to work and do normal activities. The degree to which fibromyalgia impacts a person's day-to-day life varies, and everyone's situation is unique. Working with your doctors (and other health care providers) to understand your condition and manage your symptoms, learning effective coping techniques, and having strong family and social support can really help improve and maintain your quality of life.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Fibromyalgia (The Basics)
Patient education: Myalgic encephalomyelitis/chronic fatigue syndrome (The Basics)
Patient education: Complex regional pain syndrome (The Basics)
Patient education: Sjögren's syndrome (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Headache causes and diagnosis in adults (Beyond the Basics)
Patient education: Irritable bowel syndrome (Beyond the Basics)
Patient education: Diagnosis of interstitial cystitis/bladder pain syndrome (Beyond the Basics)
Patient education: Sleep apnea in adults (Beyond the Basics)
Patient education: Myalgic encephalomyelitis/chronic fatigue syndrome (Beyond the Basics)
Patient education: Depression in adults (Beyond the Basics)
Patient education: Lyme disease symptoms and diagnosis (Beyond the Basics)
Patient education: Systemic lupus erythematosus (Beyond the Basics)
Patient education: Rheumatoid arthritis symptoms and diagnosis (Beyond the Basics)
Patient education: Osteoarthritis symptoms and diagnosis (Beyond the Basics)
Patient education: Axial spondyloarthritis, including ankylosing spondylitis (Beyond the Basics)
Patient education: Polymyalgia rheumatica and giant cell arteritis (Beyond the Basics)
Patient education: Hypothyroidism (underactive thyroid) (Beyond the Basics)
Patient education: Primary hyperparathyroidism (Beyond the Basics)
Patient education: Polymyositis, dermatomyositis, and other forms of idiopathic inflammatory myopathy (Beyond the Basics)
Patient education: Depression treatment options for adults (Beyond the Basics)
Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)
Patient education: Arthritis and exercise (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Clinical manifestations and diagnosis of fibromyalgia in adults
Differential diagnosis of fibromyalgia
Pathogenesis of fibromyalgia
Initial treatment of fibromyalgia in adults
The following organizations also provide reliable health information.
●National Library of Medicine
(https://medlineplus.gov/healthtopics.html)
●National Institute of Arthritis, Musculoskeletal, and Skin Diseases
(www.niams.nih.gov/, search for "fibromyalgia")
●American College of Rheumatology
(www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Fibromyalgia)
●National Fibromyalgia Association
●The Arthritis Foundation
