Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
nonpharmacologic therapies
Mild fibromyalgia is defined as a revised fibromyalgia impact questionnaire (FIQR) severity score >30 and ≤45. Moderate fibromyalgia is defined as an FIQR severity score >45 and ≤65.[123]
Nonpharmacologic therapies are the cornerstone to the management of fibromyalgia but are often underutilized in clinical practice.
[ 
]
There is strong evidence that demonstrates short-term positive effects of nonpharmacologic conservative therapies in people with fibromyalgia. Multimodal conservative therapies also could provide benefits in the medium- and long-term.[124]
Once diagnosed with fibromyalgia, patient education is considered to be the first step in self-management, which can be effective in improving physical function and reducing pain in the short- and long-term for fibromyalgia.[125][126][127] See Patient discussions.
Randomized controlled trial evidence has demonstrated that a self-management patient education program for fibromyalgia syndrome improved disease and treatment-specific knowledge at discharge (6-12 months), subjective knowledge, pain-related control, self-monitoring and insight, communication about disease, action planning for physical activity and treatment satisfaction for inpatients with fibromyalgia compared with usual care education in inpatient rehabilitation.[128]
There is growing evidence that patients who are obese present with more severe symptoms of fibromyalgia and lower levels of quality of life, and that a higher weight negatively impacts treatment outcomes.[121][129][130][131] Therefore, weight management should be encouraged in patients with fibromyalgia.[131]
Any exercise regimens undertaken should be individualized to the patient. In practice, patients should be warned that pain and fatigue may transiently worsen as they begin to exercise. This can be mitigated by "starting low, going slow" (progressively increasing intensity/duration over weeks to months), but short bursts of high intensity exercise may suit some patients. Reasonable goals include 2-3 sessions of aerobic exercise (lasting 20-30 minutes each) and 2-3 sessions of resistance training (≥8 repetitions per exercise), recognizing that not all patients can achieve this goal. Some patients may experience prolonged post-activity exhaustion/malaise and may benefit from activity pacing, akin to recommendations for patients with chronic fatigue syndrome/myalgic encephalitis. See Myalgic encephalomyelitis (Chronic fatigue syndrome).
Many patients would likely benefit from a referral to physical therapy to discuss low-impact exercises.
Many types of physical activity that combine exercise and relaxation have been shown to be helpful at reducing pain, anxiety, depression, and fatigue, and at improving sleep quality, functional capacity, and quality of life.[120][132][133][134][135][136][137][138][139][140][141]
[ ]
[ ]
One meta-analysis proposes that the mechanism of pain should be considered when considering exercise interventions for patients with fibromyalgia. They suggest that moderate intensity global exercises performed for a long period may benefit patients with nociplastic pain predominance, and focused and intense exercises for a short period of treatment should be performed in patients with nociceptive pain predominance.[142]
Evidence has demonstrated the efficacy of cognitive behavioral therapy (CBT) to reduce symptoms of chronic pain.[120][143] One Cochrane review concluded that CBT has a small or very small beneficial effect compared with control interventions at reducing pain, disability, and distress caused by chronic pain in adult patients with chronic pain.[143]
A subsequent systematic review of psychological interventions for women with fibromyalgia (including CBT and behavioral therapy, coping strategies training, mindfulness, acceptance and commitment treatment, hypnosis, meditation, music therapy, short-term psychodynamic psychotherapy, and writing emotions) reported that the majority of psychological interventions improved the quality of life and reduced the symptoms of fibromyalgia in women.[144]
Internet-based programs incorporating education, CBT, biofeedback, and exercise can be effective in fibromyalgia, particularly for those patients unable to access personal or group provision of CBT.[145]
pharmacologic therapy
Treatment recommended for SOME patients in selected patient group
Patients with mild or moderate symptoms of fibromyalgia may improve with education and nonpharmacologic therapies alone. However, in practice, if no benefit is seen after three months of treatment, or if the patient has concomitant diseases (e.g., depression, anxiety), pharmacologic therapy should be considered.
Choice of pharmacologic treatment should be guided by individual patient symptoms. For example, a serotonin-norepinephrine reuptake inhibitor (SNRI) is a good first choice when the patient suffers from comorbid depression or fatigue, whereas a gabapentinoid may be preferred when the individual is experiencing significant comorbid sleep issues.
In practice, pharmacologic treatment may be initiated with a subtherapeutic dose to look for signs of adverse effects. The medication is then slowly titrated up (usually over weeks) to a minimum target dose. If symptoms improve, titration up to the maximum dose, or the maximum tolerated dose may be considered. The aim is to use the lowest dose which gives the best therapeutic outcomes with minimal adverse effects (most trials reported a 30% reduction in pain intensity). This is quite objective and is usually determined with the patient.
Medications should be taken for a minimum of 12 months; however, they are often taken for longer. Treatment should be withdrawn if a patient develops intolerable adverse effects, or if no improvement of symptoms is seen after at least 3 months.
Tricyclic antidepressants: meta-analyses suggest that a meaningful clinical response can be expected in about 30% of patients with fibromyalgia treated with tricyclic antidepressants.[150][151][152] However, there is no good evidence showing extension of benefit beyond 8 weeks.[153] If no benefit is seen after a trial of 6 weeks, the medication can be stopped. If the medication was initially effective but seems to have decreased efficacy, it can be temporarily discontinued and restarted. Examples of drugs within this class include amitriptyline and cyclobenzaprine (a skeletal muscle relaxant with a similar structure to amitriptyline that has similar effects to tricyclic antidepressants). Amitriptyline is often used in preference over cyclobenzaprine due to its additional benefit on mood and lower risk of adverse effects. The anticholinergic adverse effects of tricyclics often limit their tolerability, especially in older patients; however, one benefit is that they can improve sleep.
SNRIs: duloxetine and milnacipran are both approved for the treatment of fibromyalgia. Both drugs are effective in the treatment of fibromyalgia.[120][154] They have been shown to reduce weekly pain scores in patients with fibromyalgia compared with placebo.[155][156][157][158][159][160]
[ ]
Duloxetine has demonstrated comparable efficacy for the treatment of fibromyalgia compared with amitriptyline, only differing due to patient symptom profile, that is high-quality evidence suggests that duloxetine is more effective for patients experiencing mood disorders.[161] One long-term safety study reported a 50% reduction in pain in 40% of women treated with duloxetine, with a favorable risk/benefit profile for at least 12 months for the management of fibromyalgia.[162] Tolerability of these drugs can be increased by warning patients of the risk of nausea and assuring them that in most cases this is transient, and by starting the drugs at a low dose and increasing the dose slowly. Gastrointestinal distress, hyperhydrosis, and headache are the most commonly reported adverse effects with milnacipran.[156][160][163] The most common adverse effects of duloxetine are nausea and headache.[164][165]
Gabapentinoids: the efficacy of pregabalin has been demonstrated extensively, and it is approved for the treatment of fibromyalgia.[166]
[ ]
Gabapentin is similarly effective, but it is not approved for the management of this condition and has less evidence to support its use.[167] These drugs have analgesic properties as well as anxiolytic and anticonvulsant activity.[168] Meta-analyses support use of either of these agents, reporting pain reduction, improved sleep, and improved health-related quality of life.[169][170]
[ ]
[ ]
In practice, the adverse effects of gabapentin increase as the dose increases, while the adverse effect profile of pregabalin is more linear, allowing the patient to tolerate a higher dose. The twice daily dosing of pregabalin (vs. 3 times a day dosing of gabapentin) may also be preferred. The less frequent dosing of pregabalin may also be preferred.
Analgesics: there is no evidence that nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids are effective in fibromyalgia.[172][173]
If a suboptimal response is achieved or dose titration is limited by adverse effects, a combination of two or more different drug classes (e.g., an SNRI with a gabapentinoid, or an SNRI with a tricyclic antidepressant) could be trialed.[147][148][149] SNRIs and tricyclic antidepressants may be used together (e.g., the SNRI given in the morning with the tricyclic given at night); however, there is a risk of serotonin syndrome (considered rare in clinical practice) associated with using these two drug classes together. In practice, combining all three drug classes is rare.
The drugs recommended here may be used as monotherapy or combination therapy (see above). Doses should be started low and titrated gradually according to response. Some clinicians may use lower initial doses than the licensed starting doses and those presented here.
Primary options
amitriptyline: 10 mg orally once daily at bedtime initially, increase gradually according to response, maximum 75 mg/day
OR
duloxetine: 30 mg orally once daily initially, increase gradually according to response, maximum 60 mg/day
OR
milnacipran: 12.5 mg orally once daily for 1 day, followed by 12.5 mg twice daily for 2 days, then 25 mg twice daily for 4 days, then 50 mg twice daily thereafter, increase gradually according to response, maximum 200 mg/day
OR
pregabalin: 75 mg orally twice daily initially, increase gradually according to response, maximum 450 mg/day
Secondary options
cyclobenzaprine: 10 mg orally (immediate-release) once daily at bedtime initially, increase gradually according to response, maximum 40 mg/day given in 1-3 divided doses
OR
gabapentin: 300 mg orally once daily on day 1, followed by 300 mg twice daily for 1 day, then 300 mg three times daily thereafter, increase gradually according to response, maximum 2400 mg/day
nonpharmacologic therapies
Severe fibromyalgia is defined as an revised fibromyalgia impact questionnaire (FIQR) severity score >65.[123]
Initial treatment for patients with severe fibromyalgia should include nonpharmacologic (in addition to pharmacologic therapies).
Nonpharmacologic therapies are the cornerstone to the management of fibromyalgia, but they are often underutilized in clinical practice.
[ ]
There is strong evidence that demonstrates short-term positive effects of nonpharmacologic conservative therapies in people with fibromyalgia. Multimodal conservative therapies also could provide benefits in the medium- and long-term.[124]
Once diagnosed with fibromyalgia, patient education is considered to be the first step in self-management, which can be effective in improving physical function and reducing pain in the short- and long-term for fibromyalgia.[125][126][127] See Patient discussion.
Randomized controlled trial evidence has demonstrated that a self-management patient education program for fibromyalgia syndrome improved disease and treatment-specific knowledge at discharge (6-12 months), subjective knowledge, pain-related control, self-monitoring and insight, communication about disease, action planning for physical activity, and treatment satisfaction for inpatients with fibromyalgia compared with usual care education in inpatient rehabilitation.[128]
There is growing evidence that patients who are obese present with more severe symptoms of fibromyalgia and lower levels of quality of life, and that a higher weight negatively impacts treatment outcomes.[121][129][130][131] Therefore, weight management should be encouraged in patients with fibromyalgia.[131]
Any exercise regimens undertaken should be individualized to the patient. In practice, patients should be warned that pain and fatigue may transiently worsen as they begin to exercise. This can be mitigated by "starting low, going slow" (progressively increasing intensity/duration over weeks to months), but short bursts of high intensity exercise may suit some patients. Reasonable goals include 2-3 sessions of aerobic exercise (lasting 20-30 minutes each) and 2-3 sessions of resistance training (≥8 repetitions per exercise), recognizing that not all patients can achieve this goal. Some patients may experience prolonged post-activity exhaustion/malaise and may benefit from activity pacing, akin to recommendations for patients with chronic fatigue syndrome/myalgic encephalitis. See Myalgic encephalomyelitis (Chronic fatigue syndrome).
Many patients would likely benefit from a referral to physical therapy to discuss low-impact exercises.
Many types of physical activity that combine exercise and relaxation have been shown to be helpful at reducing pain, anxiety, depression, and fatigue, and at improving sleep quality, functional capacity, and quality of life.[120][132][133][134][135][136][137][138][139][140][141]
[ ]
[ ]
One meta-analysis proposes that mechanism of pain should be considered when considering exercise interventions for patients with fibromyalgia. They suggest that moderate intensity global exercises performed for a long period of treatment may benefit patients with nociplastic pain predominance, and focused and intense exercises for a short period of treatment should be performed in patients with nociceptive pain predominance.[142]
Evidence has demonstrated the efficacy of cognitive behavioral therapy (CBT) to reduce symptoms of chronic pain.[120][143] One Cochrane review concluded that CBT has a small or very small beneficial effect compared with control interventions at reducing pain, disability, and distress caused by chronic pain in adult patients with chronic pain.[143]
A subsequent systematic review of psychological interventions for women with fibromyalgia (including CBT and behavioral therapy, coping strategies training, mindfulness, acceptance and commitment treatment, hypnosis, meditation, music therapy, short-term psychodynamic psychotherapy, and writing emotions) reported that the majority of psychological interventions improved the quality of life and reduced the symptoms of fibromyalgia in women.[144]
Internet-based programs incorporating education, CBT, biofeedback, and exercise can be effective in fibromyalgia, particularly for those patients unable to access personal or group provision of CBT.[145]
pharmacologic therapy
Treatment recommended for ALL patients in selected patient group
Initial treatment for patients with severe fibromyalgia should include pharmacologic therapies in addition to nonpharmacologic therapies.
Choice of pharmacologic treatment should be guided by individual patient symptoms. For example, a serotonin-norepinephrine reuptake inhibitor (SNRI) is a good first choice when the patient suffers from comorbid depression or fatigue, whereas a gabapentinoid may be preferred when the individual is experiencing significant comorbid sleep issues.
In practice, pharmacologic treatment may be initiated with a subtherapeutic dose to look for signs of adverse effects. The medication is then slowly titrated up (usually over weeks) to a minimum target dose. If symptoms improve, titration up to the maximum dose, or the maximum tolerated dose may be considered. The aim is to use the lowest dose which gives the best therapeutic outcomes with minimal adverse effects (most trials reported a 30% reduction in pain intensity). This is quite objective and is usually determined with the patient.
Medications should be taken for a minimum of 12 months; however, they are often taken for longer. Treatment should be withdrawn if a patient develops intolerable adverse effects, or if no improvement of symptoms is seen after at least 3 months.
Tricyclic antidepressants: meta-analyses suggest that a meaningful clinical response can be expected in about 30% of patients with fibromyalgia treated with tricyclic antidepressants.[150][151][152] However, there is no good evidence showing extension of benefit beyond 8 weeks.[153] If no benefit is seen after a trial of 6 weeks, the medication can be stopped. If the medication was initially effective but seems to have decreased efficacy, it can be temporarily discontinued and restarted. Examples of drugs within this class include amitriptyline and cyclobenzaprine (a skeletal muscle relaxant with a similar structure to amitriptyline that has similar effects to tricyclic antidepressants). Amitriptyline is often used in preference over cyclobenzaprine due to its additional benefit on mood and lower risk of adverse effects. The anticholinergic adverse effects of tricyclics often limit their tolerability, especially in older patients; however, one benefit is that they can improve sleep.
SNRIs: duloxetine and milnacipran are both approved for the treatment of fibromyalgia. Both drugs are effective in the treatment of fibromyalgia.[120][154] They have been shown to reduce weekly pain scores in patients with fibromyalgia compared with placebo.[155][156][157][158][159][160]
[ ]
Duloxetine has demonstrated comparable efficacy for the treatment of fibromyalgia compared with amitriptyline, only differing due to patient symptom profile, that is high-quality evidence suggests that duloxetine is more effective for patients experiencing mood disorders.[161] One long-term safety study reported a 50% reduction in pain in 40% of women treated with duloxetine, with a favorable risk/benefit profile for at least 12 months for the management of fibromyalgia.[162] Tolerability of these drugs can be increased by warning patients of the risk of nausea and assuring them that in most cases this is transient, and by starting the drugs at a low dose and increasing the dose slowly. Gastrointestinal distress, hyperhydrosis, and headache are the most commonly reported adverse effects with milnacipran.[156][160][163] The most common adverse effects of duloxetine are nausea and headache.[164][165]
Gabapentinoids: the efficacy of pregabalin has been demonstrated extensively, and it is approved for the treatment of fibromyalgia.[166]
[ ]
Gabapentin is similarly effective, but it is not approved for the management of this condition and has less evidence to support its use.[167] These drugs have analgesic properties as well as anxiolytic and anticonvulsant activity.[168] Meta-analyses support use of either of these agents, reporting pain reduction, improved sleep, and improved health-related quality of life.[169][170]
[ ]
[ ]
In practice, the adverse effects of gabapentin increase as the dose increases, while the adverse effect profile of pregabalin is more linear, allowing the patient to tolerate a higher dose. The twice daily dosing of pregabalin (vs. 3 times a day dosing of gabapentin) may also be preferred. The less frequent dosing of pregabalin may also be preferred.
Analgesics: there is no evidence that nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids are effective in fibromyalgia.[172][173]
If a suboptimal response is achieved or dose titration is limited by adverse effects, a combination of two or more different drug classes (e.g., an SNRI with a gabapentinoid, or an SNRI with a tricyclic antidepressant) could be trialed.[147][148][149] SNRIs and tricyclic antidepressants may be used together (e.g., the SNRI given in the morning with the tricyclic given at night); however, there is a risk of serotonin syndrome (considered rare in clinical practice) associated with using these two drug classes together. In practice, combining all three drug classes is rare.
The drugs recommended here may be used as monotherapy or combination therapy (see above). Doses should be started low and titrated gradually according to response. Some clinicians may use lower initial doses than the licensed starting doses and those presented here.
Primary options
amitriptyline: 10 mg orally once daily at bedtime initially, increase gradually according to response, maximum 75 mg/day
OR
duloxetine: 30 mg orally once daily initially, increase gradually according to response, maximum 60 mg/day
OR
milnacipran: 12.5 mg orally once daily for 1 day, followed by 12.5 mg twice daily for 2 days, then 25 mg twice daily for 4 days, then 50 mg twice daily thereafter, increase gradually according to response, maximum 200 mg/day
OR
pregabalin: 75 mg orally twice daily initially, increase gradually according to response, maximum 450 mg/day
Secondary options
cyclobenzaprine: 10 mg orally (immediate-release) once daily at bedtime initially, increase gradually according to response, maximum 40 mg/day given in 1-3 divided doses
OR
gabapentin: 300 mg orally once daily on day 1, followed by 300 mg twice daily for 1 day, then 300 mg three times daily thereafter, increase gradually according to response, maximum 2400 mg/day
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
Use of this content is subject to our disclaimer