Fibromyalgia

Fibromyalgia is a common chronic pain syndrome characterised by widespread musculoskeletal pain, fatigue, cognitive disturbance ("fibro fog"), and sleep dysfunction. It is not an inflammatory arthritis and causes no structural joint damage. It is the second most common musculoskeletal condition seen in rheumatology clinics, and is predominantly managed in general practice. Understanding fibromyalgia as a disorder of central sensitisation — rather than peripheral tissue damage — is essential to providing effective, evidence-based care.

Fibromyalgia is now understood as a disorder of central sensitisation and dysregulation of the endogenous pain modulatory system — not peripheral tissue inflammation or damage. This understanding underpins the rationale for all effective treatments.

Central Sensitisation

• Amplified pain signalling — reduced pain thresholds and increased responsiveness to painful stimuli (hyperalgesia) and non-painful stimuli (allodynia)
• Dysregulation of descending inhibitory pain pathways — reduced serotonergic and noradrenergic inhibition of ascending pain signals
• Neuroimaging studies show altered brain processing — increased activity in pain-processing regions at rest and in response to stimuli
• Elevated levels of substance P and nerve growth factor in cerebrospinal fluid in fibromyalgia patients

Contributing Factors

Fibromyalgia presents with a characteristic constellation of symptoms. The diagnosis is clinical and requires confidence — the absence of inflammatory markers or structural changes is expected, not reassuring by chance.

Core Symptoms

Examination Findings

• Diffuse soft tissue tenderness on palpation — trigger/tender points may be present but are no longer required for diagnosis under 2010/2016 ACR criteria
• Normal joint examination — no synovitis, no joint swelling, normal range of motion
• Normal neurological examination — no focal deficits; paraesthesiae without neurological explanation are common symptom
• Allodynia may be demonstrable — light touch causing pain
• Normal musculoskeletal power and reflexes

There are no diagnostic tests for fibromyalgia. Investigations serve to exclude other conditions and reassure both the patient and clinician. Extensive investigation is counterproductive — it reinforces illness beliefs and can delay diagnosis.

Recommended Baseline Tests

• Recommended
  FBC

  Exclude anaemia, haematological malignancy. Expected normal in fibromyalgia.
• Recommended
  CRP and ESR

  Exclude inflammatory arthritis and systemic inflammatory disease. Expected normal — elevated CRP/ESR should prompt reassessment of diagnosis.
• Recommended
  TFTs (TSH)

  Hypothyroidism causes fatigue, cognitive symptoms, and myalgia — must be excluded. Expected normal in fibromyalgia.
• Recommended
  ANA (antinuclear antibody)

  Low-titre positive ANA is common in healthy individuals and in fibromyalgia (up to 15%). Positive ANA alone does NOT diagnose SLE or CTD — requires clinical context and further testing.
• Recommended
  Creatinine kinase (CK)

  Exclude inflammatory myopathy — elevated CK suggests myositis, not fibromyalgia.
• Recommended
  UEC, LFTs, fasting glucose

  General metabolic screen. Relevant for medication planning (renal function for gabapentinoids, LFTs for duloxetine/amitriptyline).
• Available if indicated
  RF and anti-CCP

  If clinical features suggest inflammatory arthritis. Low-titre RF positive in ~5% of normal population — interpret with caution.
• Available if indicated
  Vitamin D and B12

  Deficiency causes fatigue and myalgia — exclude in appropriate clinical context. Replacement helps if deficient but does not treat fibromyalgia.
• Not routinely indicated
  Imaging (X-ray, MRI, bone scan)

  Not required for fibromyalgia diagnosis. Incidental findings on imaging are common and may distract from the correct diagnosis. Request only if specific musculoskeletal pathology is clinically suspected.

Fibromyalgia severity can be assessed using validated tools. Stratification helps guide the intensity and type of management and identifies patients who require more intensive multidisciplinary support.

Validated Assessment Tools

• Widespread Pain Index (WPI) + Symptom Severity Scale (SSS) — 2010/2016 ACR diagnostic criteria; WPI ≥7 + SSS ≥5, or WPI 4–6 + SSS ≥9; no tender point count required
• Fibromyalgia Impact Questionnaire Revised (FIQR) — validated measure of fibromyalgia impact on function, symptoms, and overall impact; useful for monitoring
• PHQ-9 — screen for depression (co-morbid in up to 50%)
• GAD-7 — screen for anxiety
• Pittsburgh Sleep Quality Index (PSQI) — assess sleep quality; relevant for targeting treatment

Pharmacological treatment is adjunctive in fibromyalgia — it does not address the underlying central sensitisation and should not be the primary treatment. The most effective treatments are non-pharmacological. Medications are indicated when symptoms significantly impair function or sleep and non-pharmacological approaches alone are insufficient.

First-Line Pharmacological Agents

Second-Line Pharmacological Agents

Non-pharmacological therapies are the cornerstone of fibromyalgia management and have the strongest evidence base. Exercise, patient education, and psychological therapy address the underlying central sensitisation mechanisms that pharmacological agents cannot resolve.

Exercise — The Most Effective Treatment

• Aerobic exercise has the highest-quality evidence for fibromyalgia — improves pain, fatigue, mood, and function. Start low, go slow — excessive initial exercise worsens symptoms and leads to dropout
• Graduated approach: begin at 10–15 minutes of light aerobic activity 3×/week; increase by 10–15% per week as tolerated; target 150 minutes/week moderate intensity over months
• Suitable activities: walking, hydrotherapy/warm water exercise (particularly effective), cycling, swimming, gentle yoga
• Pacing is essential — educate patients about post-exertional symptom flares and how to pace activity to avoid the "boom-bust" cycle
• Resistance training also effective — improves strength and reduces pain; target major muscle groups 2×/week
• Physiotherapy referral for supervised exercise program — particularly beneficial for patients who are deconditioned or have significant functional impairment

Psychological Therapy

• Cognitive Behavioural Therapy (CBT) — strong evidence; addresses pain catastrophising, unhelpful beliefs about pain, activity avoidance, and sleep hygiene. Available via psychology referral (Mental Health Care Plan, up to 10 sessions under Medicare)
• Acceptance and Commitment Therapy (ACT) — particularly effective for fibromyalgia; focuses on psychological flexibility and values-based living despite pain
• Mindfulness-based stress reduction (MBSR) — evidence for pain, sleep, and psychological wellbeing
• Group-based pain management programs — cost-effective; peer support; widely available through pain medicine and psychology services
• Address co-morbid depression and anxiety — independent treatment of these conditions improves fibromyalgia outcomes

Patient Education — Essential Component

• Explain fibromyalgia as a real neurobiological condition — central sensitisation is a well-validated mechanism, not "all in the head"
• Teach the biopsychosocial model of pain — validate the patient's experience while explaining modifiable factors
• Pain neuroscience education (PNE) — explaining how the nervous system amplifies pain signals reduces catastrophising and improves engagement with active treatments
• Set realistic expectations — there is no cure; goal is improved function and quality of life, not complete pain elimination
• Empower self-management — sleep hygiene, pacing, stress reduction, activity management
• Advise against "diagnosis shopping" and excessive investigations — these reinforce illness behaviour and delay recovery

Fibromyalgia flares are common and are often triggered by physical or psychological stressors. Management of flares reinforces the core principles of self-management rather than escalating pharmacological treatment.

Managing Fibromyalgia Flares

• Identify the trigger if possible — stress, illness, infection, sleep disruption, overactivity
• Rest appropriately — avoid complete inactivity but reduce activity to a comfortable baseline; resume gradually
• Reassurance — reinforce that flares are a normal part of fibromyalgia, not an indication of disease progression or worsening tissue damage
• Maintain sleep hygiene — prioritise sleep regularity and routine even during flares
• Heat application — warm baths, heat packs, hydrotherapy are commonly helpful
• Breathing and relaxation techniques — diaphragmatic breathing, progressive muscle relaxation
• Avoid escalating medications during flares — tolerance to "rescue" analgesia develops rapidly and perpetuates the pain cycle

Multidisciplinary Team

• GP — central coordinating role; diagnosis, education, medication management, Mental Health Care Plan, chronic disease management plan
• Physiotherapist — graduated exercise program, hydrotherapy, manual therapy (limited role), pacing education
• Psychologist — CBT/ACT for pain catastrophising, depression, anxiety, sleep
• Occupational therapist — workplace and activity modification, fatigue management strategies, pacing
• Pain medicine specialist — complex cases, opioid tapering, interventional options (limited evidence in fibromyalgia)
• Rheumatologist — diagnostic uncertainty, co-existent inflammatory arthritis

Sleep Hygiene

• Consistent sleep and wake times — even on weekends
• Avoid caffeine after midday; limit alcohol (worsens sleep architecture)
• Bedroom for sleep only — no screens, no work
• Wind-down routine — 30–60 minutes before bed
• Address sleep apnoea if suspected — co-morbid in fibromyalgia; polysomnography if clinically indicated
• Low-dose amitriptyline (10–25 mg) nocte is first-line pharmacological sleep support

Monitoring in fibromyalgia focuses on functional outcomes, treatment response, and the assessment of co-morbidities — not laboratory parameters, which are expected to remain normal.

When to Refer

• Rheumatology: Diagnostic uncertainty — features of inflammatory arthritis, positive ANA/RF with clinical concern, or failure to diagnose with confidence
• Pain medicine: Severe fibromyalgia not responding to first- and second-line management; opioid dependency requiring structured tapering; consideration of multidisciplinary pain program
• Psychology: Significant co-morbid depression, anxiety, or pain catastrophising; CBT/ACT referral (Mental Health Care Plan)
• Sleep medicine: Suspected sleep apnoea contributing to non-restorative sleep
• Physiotherapy: All patients — for graduated exercise program and pacing education

Fibromyalgia occurs across the lifespan and several populations require modified approaches.

Fibromyalgia Co-existing with Inflammatory Arthritis

• Central sensitisation (fibromyalgia) commonly co-exists with rheumatoid arthritis, SLE, ankylosing spondylitis, and psoriatic arthritis — reported in 20–30% of RA patients
• Central sensitisation symptoms in inflammatory arthritis patients are often misattributed to active disease — this leads to unnecessary immunosuppression escalation
• Key distinction: fibromyalgia pain does not correlate with inflammatory markers or joint examination findings; inflammatory disease activity does
• Management requires separate treatment strategies for each condition
• Communicate clearly with the rheumatologist about suspected fibromyalgia overlay

Fibromyalgia in Men

• Men with fibromyalgia are frequently under-diagnosed — fibromyalgia has historically been considered a condition predominantly affecting women
• Men more commonly present with predominantly physical symptoms (fatigue, pain) and less commonly acknowledge psychological components
• Same diagnostic criteria and management principles apply

Fibromyalgia in Older Adults

• Fibromyalgia in older adults must be distinguished from OA, inflammatory arthritis, and polymyalgia rheumatica (PMR)
• PMR: proximal muscle girdle pain + stiffness + elevated CRP/ESR + rapid corticosteroid response — different from fibromyalgia
• Avoid polypharmacy — amitriptyline causes falls, anticholinergic burden; pregabalin/gabapentin increase falls risk in elderly
• Physical exercise especially important — maintains function and independence

Fibromyalgia and Pregnancy

• Many fibromyalgia symptoms fluctuate during pregnancy — may worsen in first trimester, sometimes improve in third trimester
• Avoid duloxetine and tricyclics in pregnancy where possible — limited safety data; neonatal adaptation syndrome risk with SNRIs
• Pregabalin: avoid in pregnancy (teratogenicity in animal studies; limited human data)
• Non-pharmacological approaches (exercise, physiotherapy, hydrotherapy, psychological support) are first-line in pregnancy
• Obstetric team should be aware of fibromyalgia diagnosis — impacts pain management planning for labour

Fibromyalgia is associated with significant over-investigation, inappropriate pharmacological management, and high healthcare utilisation. Stewardship is critical to avoiding harm and improving outcomes.

GP Role — Coordinating Effective Care

• Make the diagnosis confidently — a clear diagnosis is the first therapeutic intervention
• Provide a thorough explanation of fibromyalgia and central sensitisation — allocate time; use written resources
• Issue a Mental Health Care Plan for psychology referral (CBT/ACT)
• Refer to physiotherapy for graduated exercise
• Use the Chronic Disease Management (CDM) plan for allied health coordination
• Review and rationalise medications — avoid opioids, wean if present, minimise polypharmacy
• Maintain a therapeutic alliance — patients with fibromyalgia frequently feel dismissed; empathy and validation improve engagement with treatment

Follow-up in fibromyalgia should focus on functional outcomes, treatment adherence, and addressing barriers to self-management. Regular but not excessive follow-up maintains the therapeutic relationship without reinforcing excessive illness behaviour.

Prevention of Fibromyalgia Chronification

• Early diagnosis and education — avoiding diagnostic uncertainty reduces psychological distress and catastrophising
• Early exercise initiation — delay worsens deconditioning and central sensitisation
• Address psychological co-morbidities early — untreated depression and anxiety drive chronification
• Avoid opioids from the outset — opioid prescribing in early fibromyalgia worsens outcomes
• Maintain employment where possible — work participation is associated with better outcomes; occupational therapy and workplace accommodation can help

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