Overview
Fibromyalgia is a chronic condition characterised by widespread musculoskeletal pain with associated fatigue, cognitive disturbance, and sleep issues. It is considered a central pain processing disorder, not a primary muscle or joint disease. Diagnosis is clinical — no confirmatory lab or imaging tests, however, it is important to rule out any differentials.
Aetiology and Risk Factors
- Multifactorial:
- Genetic predisposition (e.g. family history)
- Psychological stress or trauma (physical/emotional)
- Infections (e.g. EBV, hepatitis C, Lyme disease)
- Sleep disturbances
- Female sex (F:M ratio ~9:1)
- Coexistent rheumatic diseases (e.g. RA, SLE)
Pathophysiology
- Central sensitisation: heightened pain response to normal stimuli.
- Neurotransmitter dysregulation:
- ↓ serotonin and norepinephrine (pain inhibition)
- ↑ substance P and glutamate (pain facilitation)
- Dysregulation in the hypothalamic-pituitary-adrenal (HPA) axis and autonomic nervous system.
- Sleep abnormalities (↓ slow-wave sleep).
Clinical Manifestations
- Widespread pain (≥3 months, both sides of body, above and below waist)
- Fatigue (often debilitating)
- Sleep disturbances (non-restorative sleep)
- Cognitive dysfunction (“fibro fog”)
- Other features:
- Headaches
- Irritable bowel syndrome
- Depression/anxiety/PTSD
- Paresthesias (non-dermatomal)
- Temporomandibular joint disorder
Triad: Widespread Pain + Fatigue + Cognitive Disturbance
Remember
Fibromyalgia can coexist with autoimmune disease — don’t dismiss symptoms in patients with RA/SLE.
Diagnosis
- 2016 ACR Criteria:
- Widespread Pain Index (WPI) + Symptom Severity (SS) Scale
- Symptoms present ≥3 months
- No other disorder explaining the pain
- Investigations to exclude mimics:
- TSH (rule out hypothyroidism)
- CRP/ESR (usually normal in fibromyalgia)
- ANA/RF/anti-CCP if suspicion for SLE/RA
- Differentials:
- Polymyalgia rheumatica (older age, raised ESR)
- Hypothyroidism
- RA/SLE (look for synovitis, autoantibodies)
- Myopathies
- Sleep disorders (e.g. obstructive sleep apnoea)
Remember
Fibromyalgia is a diagnosis of exclusion. Always rule out inflammatory, endocrine, or neurological causes.
Remember
CRP/ESR are typically normal — elevated markers should prompt reconsideration of diagnosis.
Treatment
Multimodal, non-pharmacologic is first-line
- Education and reassurance
- Exercise (low-impact aerobic, graded exercise program/resistance, flexibility)
- Cognitive behavioural therapy (CBT)
- Sleep hygiene
- Pacing strategies
Pharmacologic (adjunct only)
- Amitriptyline or duloxetine (SNRIs)
- Pregabalin or gabapentin (neuropathic pain modulators)
- Avoid opioids — ineffective and potentially harmful
- NSAIDs rarely helpful unless another pain generator present
Remember
Sleep is medicine non-restorative sleep can worsen all fibromyalgia symptoms.
Remember
Many patients improve with exercise alone — start low and go slow.
Complications and Prognosis
Complication
- Reduced quality of life
- Work disability
- Medication-related adverse effects
- Psychiatric comorbidity (e.g. depression, anxiety)
Prognosis
- Chronic, fluctuating course
- No structural joint damage or mortality risk
Symptoms can improve significantly with lifestyle and psychological intervention.
References
- Clauw DJ. Fibromyalgia: A clinical review. JAMA. 2014;311(15):1547-55.
- Häuser W, Ablin J, Fitzcharles MA, Littlejohn G, Luciano JV, Usui C, Walitt B. Fibromyalgia. Nat Rev Dis Primers. 2015;1:15022.
- Wolfe F, Clauw DJ, Fitzcharles MA, et al. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum. 2016;46(3):319–329.
- Arnold LM, Bennett RM, Crofford LJ, Dean LE, Clauw DJ. AAPT Diagnostic Criteria for Fibromyalgia. J Pain. 2019;20(6):611–628.
- Häuser W, Walitt B, Fitzcharles MA, Sommer C. Review of pharmacological therapies in fibromyalgia syndrome. Arthritis Res Ther. 2014;16(1):201.
Discussion