|
| A) | 0 to 12 years of age | ||
| B) | 13 to 19 years of age | ||
| C) | 20 to 55 years of age | ||
| D) | 55 to 79 years of age |
As with autoimmune diseases, the prevalence of fibromyalgia is higher among women than men, although data are conflicting. Studies have found that women are diagnosed between 2 to 14 times as often as men, depending on the criteria used [1]. Fibromyalgia is usually diagnosed between the ages of 20 and 55 years, but can affect individuals of all ages, including children [1,13].
| A) | double. | ||
| B) | three times higher. | ||
| C) | nine times higher. | ||
| D) | 100 times higher. |
Genetics is thought to be a factor in the susceptibility of fibromyalgia. Family clustering has been reported, and the risk for fibromyalgia is up to nine times higher for first-degree relatives of individuals with the syndrome [1,19]. Abnormalities in the serotonin transporter gene, dopamine receptor gene, and the catecholamine-O-methyltransferase gene have been identified [19]. These abnormalities affect the metabolism or transport of serotonin and norepinephrine, which decrease the sensitivity of pain-processing systems through the descending central nervous system pain pathways [1,19]. Additional suggested etiologies include diffuse inflammation, glial cell activation, and small fiber neuropathy [1].
| A) | Sleeping problems | ||
| B) | Emotional distress | ||
| C) | Strenuous activity | ||
| D) | Changes in the weather |
Psychiatric conditions have long been associated with fibromyalgia, and research suggests that such conditions may precede fibromyalgia and act as a trigger for the disease. In one study, when individuals were asked what they perceived to be a trigger for fibromyalgia, 73% attributed the development of the disease to emotional trauma or chronic stress; 24% noted emotional/physical abuse as an adult or child as a perceived trigger [20].
| A) | stiffness, paresthesias, and anxiety. | ||
| B) | stiffness, fatigue, and sleep abnormalities. | ||
| C) | balance problems, headaches, and dry mouth. | ||
| D) | depression, fatigue, and cognitive dysfunction. |
There is a wide range of symptoms and comorbidities associated with fibromyalgia, and they occur in a variety of combinations and differ in terms of severity. After the three primary manifestations (fatigue, stiffness, and sleep abnormalities), the most common symptoms are headaches (usually migraine), dry mouth, low back pain, and paresthesias (Table 1) [17,20,21,25,31]. In an online survey conducted by the National Fibromyalgia Association (NFA), 19 symptoms, affecting virtually all body systems, were noted by at least 25% of the respondents [20]. Nearly all individuals with fibromyalgia are polysymptomatic [20].
| A) | Fibromyalgia Impact Questionnaire-Revised | ||
| B) | Visual analog scale | ||
| C) | Brief Pain Inventory | ||
| D) | Sleep Assessment Questionnaire |
Most individuals with fibromyalgia describe pain as arising from muscles and joints and also have tender skin. Pain is typically axial in distribution, and pain/stiffness usually occurs in the morning and evening. Patients may note a feeling of swelling in the soft tissues, primarily around the joints, but there is no objective evidence of swelling. Self-reports are often used as the primary source for pain assessment, focusing on such details as [1,21]:
Type and quality of pain
Source
Location
Duration
Time course
Pain affect
Effects on quality of life
| A) | Hair loss | ||
| B) | Mental slowing | ||
| C) | Profound fatigue | ||
| D) | Muscle weakness |
DIFFERENTIAL DIAGNOSIS OF FIBROMYALGIA
| Diagnoses to Consider | Shared Manifestations | Distinguishing Features |
|---|---|---|
| Myofascial pain syndrome | Painful, tender areas in the muscles, commonly affecting the axial muscles | Pain arising from trigger points in individual muscles during examination |
| Chronic fatigue syndrome | Chronic pain and fatigue | Low-grade fever, enlargement of lymph glands, continuous subclinical inflammatory process, and acute onset of illness |
| Rheumatoid arthritis | Joint pain/stiffness | Involvement of hands and feet, positive rheumatoid factor (in 80% to 90% of cases), radiographic evidence of joint erosion |
| Systemic lupus erythematosus | Involvement of multiple systems, joint pain | Malar rash, positive antinuclear antibody test |
| Hypothyroidism | Profound fatigue, muscle weakness, mental slowing | Weight gain, hair loss, increased TSH level |
| Polymyalgia rheumatica | Pain/stiffness in sacrohumeral and pelvic girdle | Increased ESR (in 80% to 90% of cases), age older than 65 years, treatment with glucocorticoids resolves symptoms |
| Spondyloarthropathy | Pain in neck, mid-thoracic, anterior chest wall, or lumbar regions | Pain localized to specific spinal areas, radiographic evidence of sacroiliitis, or radiographic changes in vertebral bodies |
| Polyarticular osteoarthritis | Pain in multiple joints | Radiographic evidence of joint degeneration |
| Polymyositis or other myopathies | Muscle weakness | Proximal, symmetrical muscles affected, increased serum levels of muscle enzymes, abnormal findings on EMG testing and on evaluation of biopsy samples |
| Neuropathic pain syndromes | Tingling, numbness | Burning, shooting pain |
| EMG = electromyography; ESR = erythrocyte sedimentation rate; TSH = thyroid-stimulating hormone. | ||
| A) | Duloxetine | ||
| B) | Pregabalin | ||
| C) | Cyclobenzaprine | ||
| D) | Amitriptyline |
PHARMACOLOGIC TREATMENTS USED IN FIBROMYALGIA
| Drug | Dose | Common Adverse Events | Comments |
|---|---|---|---|
| Antidepressants | |||
| Amitriptyline | 25–50 mg PO at bedtime | Nausea, vomiting, dry mouth, dizziness, drowsiness, headache | Recommended "weak for" by EULAR; found effective at low dose 6 to 8 weeks; high dose did not demonstrate efficacy |
| Duloxetine | 60 mg PO daily | Nausea, dry mouth, constipation, drowsiness, decreased appetite | Approved by FDA for fibromyalgia in 2008 |
| Milnacipran | 50–100 mg PO twice daily | Nausea, headache, constipation, dizziness, hot flush, dry mouth | Approved by FDA for fibromyalgia in 2009 |
| Anticonvulsants | |||
| Pregabalin | 300–450 mg PO daily | Diarrhea, dizziness, blurred vision, dry mouth, vomiting | Approved by FDA for fibromyalgia in 2010 |
| Gabapentin | 1,200–2,400 mg PO daily | Viral infections (in children), dizziness, somnolence, ataxia | Limited data on effectiveness; Recommended "weak for" by EULAR |
| Analgesics/Muscle Relaxants | |||
| Cyclobenzaprine | 5.6 mg PO daily at bedtime | Drowsiness, xerostomia, dizziness | Approved by FDA for fibromyalgia in 2025 |
| NSAIDs | — | — | No evidence to support use, but may be of benefit in treating comorbidities |
| Glucocorticoids | — | — | No evidence to support use, but may be of benefit in treating comorbidities |
| Opioids | |||
| Low-dose (tramadol) | 200–300 mg PO daily | Hot flush, dizziness, headache, constipation, nausea | Recommended "weak for" by EULAR |
| Potent | — | — | Not recommended; should be used only if all other approaches have been exhausted |
| Sedative Hypnotics | |||
| Zolpidem | 5–10 mg PO at bedtime | Headache, somnolence, dizziness | Improves sleep; no effect on pain |
| Benzodiazepines and sedatives | — | — | Evidence of effectiveness is lacking |
| A) | The long-term safety and efficacy of pregabalin is unknown. | ||
| B) | Pregabalin and gabapentin are both approved by the FDA for the treatment of fibromyalgia. | ||
| C) | Gabapentin is associated with a higher rate of adverse events than pregabalin. | ||
| D) | Pregabalin has improved pain and fatigue but not other fibromyalgia symptoms. |
The third FDA-approved drug for the treatment of fibromyalgia is pregabalin, an anticonvulsant agent. Several studies have shown pregabalin to significantly improve pain, patient global assessment, fatigue, and health-related quality of life, as well as sleep disturbances [66,67,68]. The effect of the drug has lasted for as long as six months [66]. The drug was well tolerated, with the common side effects being dizziness and sedation, which tended to resolve with time of treatment [66].
Anticonvulsants have been evaluated in several trials, and EULAR guidelines note weak evidence for pregabalin specifically [2]. Another anticonvulsant drug, gabapentin, has also demonstrated efficacy with respect to pain, patient global assessment, function, and sleep, although it has not been approved by the FDA to treat fibromyalgia, and the drug is not specifically noted in treatment guidelines [2]. The side effect profile of gabapentin is similar to that of pregabalin, but the pharmacokinetic and pharmacodynamic profile is not as favorable [58]. The long-term safety and efficacy of both drugs is also unknown, and many patients are expected to discontinue therapy due to a high incidence of adverse effects. The overview found no evidence of clinical benefit with any other anticonvulsant, including carbamazepine [67].
| A) | fatigue. | ||
| B) | stiffness. | ||
| C) | pain and dizziness. | ||
| D) | pain and sleep disturbances. |
Strong evidence has also been documented for cyclobenzaprine, which earned the first FDA approval for fibromyalgia in more than 15 years in 2025 [59]. Cyclobenzaprine has both muscle relaxant and tricyclic antidepressant properties and is taken as a sublingual tablet daily at bedtime for management of both sleep disturbances and pain [58,59]. An early systematic review of five randomized controlled trials showed that individuals treated with cyclobenzaprine for fibromyalgia were three times as likely to report overall improvement and to note reductions in symptoms, especially sleep disturbances versus the control group [69].
| A) | Bed rest | ||
| B) | Exercise | ||
| C) | Patient education | ||
| D) | Cognitive-behavioral therapy |
The authors of one review of nonpharmacologic treatment suggest that clinicians use the acronym ExPRESS to follow principles of nonpharmacologic pain management [50]:
Ex: Exercise
P: Psychiatric (i.e., addressing psychiatric comorbidities to help improve pain and disability)
R: Regain function (helping patients pace activities to avoid doing too much on days they feel well)
E: Education (referral to reliable resources)
S: Sleep hygiene
S: Stress management (such as cognitive-behavioral therapy and relaxation techniques)