Fibromyalgia*The information on this website is not intended to diagnose, treat, cure or prevent any disease.
What is Fibromyalgia?
Fibromyalgia is a chronic condition in which the patient suffers diffuse pain of the muscles and bones, as well as increased sensitivity to pressure. Besides pain, sufferers of fibromyalgia also experience profound fatigue, numbness, tingling, and sensitivity to lights and sound. Because of all these issues, they often have associated conditions like anxiety and depression.
It is a relatively common condition, affecting somewhere between 2-4% of the population in the United States. It more frequently affects women than men. Due to its vague signs and uncertain origins, it is a condition which has historically been difficult to classify, however it is considered likely a disorder of the central nervous system’s ability to appropriately process pain. There are now considered four subtypes of fibromyalgia, however these subtypes are not mutually exclusive and mixing is also observed. Depending on the subtype, different treatments may be most appropriate. The identified types include:
- Extreme sensitivity to pain, no psychiatric conditions
- Fibromyalgia and pain-related depression
- Fibromyalgia and depression
- Fibromyalgia due to manifestation of psychologic distress as pain (somatization)
Many people with fibromyalgia also have difficulties with memory, or experience “brain fog” or “fibro fog” which causes loss of focus, difficulty multitasking, and reduced attention spans. Fibromyalgia commonly occurs in people with autoimmune disorders like systemic lupus erythematosus and rheumatoid arthritis.
Fibromyalgia signs can be vague, but typically include widespread pain, although focused areas of pain are also possible. Signs include
- Widespread pain
- Increased sensitivity to touch/pressure
- Tingling of the skin
- Muscle twitching
- Temporomandibular joint dysfunction
- Restless leg syndrome
- Bladder pain or difficulty urinating
- Difficulty sleeping
- Poor attention span
- Difficulty concentrating
In the past, fibromyalgia was diagnosed on the basis of tenderness at 18 different pressure points on the body. Those guidelines have been discontinued, and the only major criteria needed for a diagnosis is chronic, widespread pain for greater than 3 months without any other condition which would explain the pain. Although specific diagnostic tests are note needed to diagnose fibromyalgia, some tests may be necessary to rule out other causes of pain or to check for other concurrent conditions.
Tests which may aid in the diagnosis of fibromyalgia include:
- Blood Tests
- Erythrocyte sedimentation rate: This test can help screen for autoimmune diseases which can occur in conjunction with fibromyalgia, or present with similar signs to fibromyalgia.
- Rheumatoid factor: This test screens for the presence of proteins generated by the immune system. It can help differentiate fibromyalgia from rheumatoid arthritis and other autoimmune diseases.
- Blood Tests
- C-Reactive Protein: C-reactive protein is another inflammatory protein elevated in a variety of conditions. As fibromyalgia occurs in the absence of inflammation, C-reactive protein would not be expected to be elevated.
- Anti-nuclear antibodies: These are specific antibodies commonly produced in autoimmune conditions.
- Cyclic citrullinated peptide antibodies: These are specific markers associated with rheumatoid arthritis
- Thyroid function: An underactive thyroid gland can produce muscle pain similar to that experienced by fibromyalgia sufferers.
- Infectious Disease Testing: Conditions like Lyme disease often result in chronic pain. In areas in which Lyme disease is endemic, or in people who have a lifestyle which puts them at higher risk, this may be recommended to rule out a cause.
- Imaging: X-rays or other advanced imaging may be helpful to ensure that there are not underlying problems like fractures causing chronic pain. Although fibromyalgia is usually widespread pain, sometimes it can be focused over a certain area, which can make diagnosis more difficult.
There is no known cure for fibromyalgia. The goal of treatment is to improve quality of life and reduce the symptoms as much as feasibly possible. This may include medical and non-medical approaches.
Pharmaceuticals and Medical Procedures:
- Antidepressants: Unexpectedly, antidepressant medications seem to help modulate the pain in many people with fibromyalgia. Antidepressants which have specifically been found to benefit fibromyalgia sufferers are the selective serotonin reuptake inhibitors (SSRIs) duloxetine (Cymbalta) and milnacipran (Savella). The tricyclic antidepressant amitriptyline has also been helpful, but has a broader range of undesirable side effects. It can take weeks to months to begin experiencing positive benefits from these medications.
- Opioid Pain Medications: Generally, strong opioids are not recommended due to their addictive potential. Over time, as the body becomes dependent, they may even make the pain worse, and higher and higher doses of opioids may be required to achieve the same effect. However, weak opioid drugs, such as tramadol, may be beneficial long term. Available evidence has not shown tramadol to be superior to acetaminophen, and it is thought that its pain-relieving properties are not due to its actions at opioid receptors, but its effects on serotonin and norepinephrine reuptake inhibition, similar to some antidepressants.
- Non-opioid Pain Medication: Many over the counter medications like non-steroid anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil) and naproxen (Aleve) may be helpful in some people, but they are not usually recommended as first-line options. Acetaminophen (Tylenol) is another non-NSAID option.
- Anti-convulsants: Gabapentin (Neurontin) is an anti-convulsant medication which also has pain relieving properties, particularly when the pain is associated with the nervous system. Pregabalin (Lyrica) is similar in this regard. These drugs unfortunately work in a limited number of people – about 1 in 5 for gabapentin and about 1 in 11 for pregabalin. They also often have side effects which make long-term use difficult, such as dizziness, difficulty walking, and fluid retention.
- Growth Hormone: Growth hormone supplementation or medications which increase growth hormone production may reduce fibromyalgia symptoms, however it can have a wide range of undesirable side effects.
- Muscle Relaxants: Cyclobenzaprine and carisoprodol may help support sleep in patients with fibromyalgia
- Naltrexone: This is a serotonin receptor antagonist which may provide some relief in people with fibromyalgia.
- Medical Marijuana/Synthetic THC: Currently, it is unclear if these are overall beneficial in people with fibromyalgia. Some studies which have been conducted suggest there may be a benefit, however there were also very high dropout rates due to side effects.
- Antibiotics: For those who have fibromyalgia symptoms possibly related to Lyme disease, antibiotics may be warranted.
There are many non-pharmaceutical therapies for fibromyalgia which may be beneficial in some people.
- Cognitive Behavioral Therapy (CBT): When used in combination with other approaches, CBT can be an effective component at reducing symptoms of fibromyalgia. Although fibromyalgia is not considered a psychiatric disorder, chronic pain can result in depression and anxiety. CBT can not only help manage these concurrent conditions, but it can also help people learn to focus less on the pain, symptoms, and distress which accompanies fibromyalgia.
- Physical Therapy: Specific exercise programs can help improve flexibility and reduce pain.
- Occupational Therapy: This is an approach which seeks to improve productivity by adjusting work habits and ergonomics. By adjusting movements, postures, and certain habits, pain can be reduced or eliminated, and productivity improved.
- Exercise: This should be considered part of a multimodal approach to fibromyalgia, along with CBT and other therapies. Exercise can help improve sleep quality, reduce stress levels, and increase energy levels while reducing pain. Some studies which have incorporated exercise into treatment programs for children have achieved complete pain control in nearly 9 out of 10 participants.
- Heat/Sauna Therapy: Thermal sauna therapy may improve pain and quality of life in people with fibromyalgia. This can also help remove toxins from the body via sweat.
- Establish Good Sleep Hygiene: Disturbed sleep is an important component of fibromyalgia symptoms. Good sleep hygiene can improve feelings of fatigue and reduce neuroinflammation.
- Mind Body Techniques:
- Mindfulness/Meditation: Mindful meditation techniques are helpful for many people with chronic pain conditions. These techniques help reduce the stress which comes with pain, and can modify the way people think or focus on pain in the daily lives.
- Acupuncture: Acupuncture has mixed results when evaluated in clinical trials, with some trials finding no benefit and others finding a significant benefit. The effect may strongly depend on the individual, just as many of the medical approaches do. The major benefit found in some trials was not necessarily for pain relief, but anxiety and fatigue.
- Massage Therapy: Massage therapy has been shown to improve anxiety, sleep quality, pain, and overall quality of life in people with fibromyalgia over the short term. Over the long-term, many of these factors returned to baseline once massage therapy was discontinued, however people who were treated continued to have improved sleep quality. Continued massage therapy may provide long-term benefits.
- Hypnotherapy: Small trials have found hypnotherapy to be helpful in people who are suffering from fibromyalgia refractory to other treatments.
- Chiropractic Therapy: Chiropractic care can improve pain levels and range of motion in the neck and lower back.
- Biofeedback: This approach allows people to monitor their biologic responses while connected to an electromyogram (EMG) or electroencephalogram (EEG). While monitoring their own body’s responses, a person can learn to modify things like muscle tension and pain.
- 5-Hhydroxytrptophan (5-HTP): This is a precursor to serotonin, which seems to be involved in the fibromyalgia. This can help improve sleep quality, reduce depression, as well as pain. This should be taken with caution, particularly if antidepressant medications or other supplements such as St. John’s Wort are being taken, as it can result in excessive serotonin and a potentially life-threatening condition called serotonin syndrome.
- Melatonin: Melatonin is the hormone which helps regulate sleep, but it has many other effects in the body. Some people find pain relief through melatonin, and it can help improve sleep quality as well.
- St. John’s Wort: This is a natural herb which may act as a selective serotonin reuptake inhibitor. People with fibromyalgia may find some benefit through this herb. It should not be combined with prescription antidepressants, and used cautiously with other supplements due to the risk of serotonin syndrome.
- L-Carnitine: This amino acid is abundant in muscle tissue and it may help reduce fatigue in people with fibromyalgia.
- SAM-e: SAM-e is another supplement which may increase serotonin and/or dopamine levels in the brain. It may be useful for depression associated with fibromyalgia.
- Fish Oil: Some people may find benefit with fish oil, which may reduce inflammation in the nervous system. Fish oil can be helpful in some people suffering from depression, which often occurs with fibromyalgia.
- Vitamin D: Vitamin D has shown success in a clinical trial of women suffering from fibromyalgia, reducing pain and fatigue within one week.
- Ribose: This is a sugar which is readily metabolized by muscles. One study found that it may reduce pain by approximately 15% in people with fibromyalgia, as well as improve muscle relaxation.
- Magnesium: This basic mineral is involved in over 300 metabolic processes, including muscle and nerve health. It can help improve sleep quality and muscle relaxation, reducing cramps, spasms, and weakness. It may also help relieve pain associated with fibromyalgia.
- Boswellia: This herb has activities similar to many NSAID drugs and may be helpful in pain management.
- Ashwagandha: Known as “Indian ginseng,” ashwagandha seems to help relieve stress and anxiety in many people, and may be helpful for those suffering from fibromyalgia.
- Probiotics: Many people with fibromyalgia may have digestive problems. Probiotics can help regulate gastrointestinal health and promote overall wellness.
- Dietary Modifications:
- Chelation therapy: Heavy metals are frequently high in patients with fibromyalgia. It is possible that heavy metals toxicity triggers the chronic pain associated with it. Chelation therapy with EDTA or Succimer can help remove these compounds from the body.
There is no definitive way to prevent fibromyalgia, however it needs to be well-managed after it arises in order to reduce symptoms. The best way to prevent symptoms from becoming severe or life-limiting is to ensure healthy sleeping patterns, and managing stress through exercise, meditation, and relaxation techniques. Additionally, eating a healthy diet rich in vitamin D, magnesium, and antioxidants is very important for long-term healthy and maintaining a quality of life. Some foods may exacerbate symptoms, such as those high in glutamate. Many foods use monosodium glutamate (MSG) as a flavor enhancer, and this can exacerbate symptoms. Other foods which may make management more difficult include caffeine, which can interrupt sleeping cycles as well as promote feelings of anxiety. Foods high in unhealthy fats or refined sugars should also be avoided.
Once a treatment regimen is established, it is important to adhere to it. Usually, fibromyalgia is best-managed through a combination of medication, cognitive behavioral therapy, exercise, sleep hygiene, and maintain an overall healthy lifestyle.
There is no known definitive cause of fibromyalgia. The disorder appears to be due to inappropriate processing of pain signals in the central nervous system. What leads to this dysfunction is unclear, but in some people, there appears to be a genetic predisposition, as it runs in families. There is no single gene involved, but it is likely due to multiple genes in these individuals.
Inflammation of the nervous system is thought to be a contributing factor in fibromyalgia. Sufferers tend to have increases in certain inflammatory cytokines which may increase pain sensitivity and affect mood. There may be many reasons why inflammation occurs, but it may be due to immune dysregulation or chronic infections. Some infections which have been suspected to be linked to fibromyalgia are viruses like Epstein-Barr, which is responsible for the condition mononucleosis and is suspected to play a role in a variety of other conditions as well. Other commonly implicated viruses include human herpes virus-6 (HHV-6), Varicella zoster (chickenpox) virus, herpes simplex 1 and 2, and cytomegalovirus (CMV). All of these viruses have the ability to develop into chronic, latent infections which are never completely cleared by the body. Ongoing infection may result in chronic inflammation as the body unsuccessfully tries to clear these viruses. Many of them also tend to target nervous tissue, which seems to be where the site of dysfunction occurs in fibromyalgia.
Bacterial infections may also be responsible for fibromyalgia. Mycoplasma pneumoniae is a tiny bacterium which is adept at evading the immune system and difficult to treat with antibiotics. It can travel around the body within white blood cells and end up in places like joints, muscles, and nerves, where it goes on to induce inflammation. Another bacterium which have some role in fibromyalgia is Borrelia burgdorferi, the causative agent of Lyme disease. This bacterium is a master at evading the immune system and causing a myriad of physical symptoms. It sometimes travels to the nervous system, causing neuroinflammation and other signs. There is speculation that fibromyalgia may be another manifestation of Lyme disease in some people.
Heavy metal toxicity may also be responsible for some cases. Many of the symptoms of fibromyalgia fit into signs seen with heavy metal toxicosis, and patients with fibromyalgia frequently have higher levels of heavy metals in their bodies than unaffected people. Mercury, lead, cadmium, and manganese are only a few that may contribute to the neurologic dysfunction seen in fibromyalgia. Amalgam fillings, contaminated drinking water, and exposure to industrial contaminants may result in accumulation of these toxins in the body, eventually manifesting as fibromyalgia.
Fibromyalgia may also be due to mold toxicity. Chronic exposure to molds and their toxins can result in chronic inflammation, pain, and general feelings of malaise. For some people with fibromyalgia, mold in the environment may be playing a role.
Finally, fibromyalgia may also be related to chronic poor sleep, which disrupts the natural repair mechanisms in the body and decreases the amount of growth hormone. Long-standing poor sleep can result in increased sensitivity to pain, while correction actually reduces pain in people. People who have other conditions which disrupt sleep like insomnia, depression, or post-traumatic stress disorder may also develop fibromyalgia. Interestingly, fibromyalgia may be triggered by psychological stress, which may first disrupt normal sleeping habits.
Clinics for Management of Fibromyalgia
Stanford University Division of Pain Medicine