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For further information, see CMDT Part 20-45: Fibromyalgia

Key Features

Essentials of Diagnosis

  • Most frequent in women aged 20–50

  • Chronic widespread musculoskeletal pain syndrome with multiple tender points

  • Fatigue, headaches, numbness common

  • Objective signs of inflammation absent; laboratory studies normal

General Considerations

  • Affects 3–10% of the general population

  • Cause is unknown, but aberrant perception of painful stimuli, sleep disorders, depression, and viral infections have all been proposed

  • Shares many features with the myalgic encephalomyelitis/chronic fatigue syndrome

    • An increased frequency among women aged 20–50

    • Absence of objective findings

    • Absence of diagnostic laboratory test results

  • While many of the clinical features of the two conditions overlap, musculoskeletal pain predominates in fibromyalgia whereas lassitude dominates the myalgic encephalomyelitis/chronic fatigue syndrome

  • Fibromyalgia can be a complication of hypothyroidism, rheumatoid arthritis or, in men, sleep apnea

Clinical Findings

Symptoms and Signs

  • Chronic aching pain and stiffness, frequently involving the entire body but with prominence of pain around the neck, shoulders, low back, and hips

  • Fatigue, sleep disorders, subjective numbness, chronic headaches, and irritable bowel symptoms are common

  • Even minor exertion aggravates pain and increases fatigue

  • Physical examination is normal except for "trigger points" of pain produced by palpation of various areas such as

    • Trapezius

    • Medial fat pad of the knee

    • Lateral epicondyle of the elbow

Differential Diagnosis

  • Rheumatoid arthritis

  • Systemic lupus erythematosus

  • Polymyositis produces weakness rather than pain

  • Polymyalgia rheumatica

    • Produces shoulder and girdle pain

    • Is associated with an elevated sedimentation rate and anemia

    • Occurs after age 50

  • Hypophosphatemic states, such as oncogenic osteomalacia


  • Diagnosis of exclusion

  • Thyroid function tests are useful because hypothyroidism can produce a secondary fibromyalgia syndrome


Conservative Measures

  • Patient education is essential; while therapies are imperfect, course is not progressive

  • Cognitive behavioral therapy, including programs that emphasize mindfulness meditation, is often helpful

  • Exercise programs are also beneficial

  • Acupuncture is not effective


  • The following have modest efficacy:

    • Amitriptyline

      • Initiated at a dosage of 10 mg orally at bedtime and gradually increased to 40–50 mg depending on efficacy and toxicity

      • Less than 50% of the patients experience a sustained improvement

    • Fluoxetine

    • Duloxetine

    • Milnacipran

    • Chlorpromazine

    • Cyclobenzaprine

    • Pregabalin

    • Gabapentin

  • Nonsteroidal anti-inflammatory drugs are generally ineffective

  • Tramadol and acetaminophen combinations have ameliorated symptoms modestly in short-term trials

  • Opioids and corticosteroids are ineffective and should not be used to treat fibromyalgia



  • All patients have chronic symptoms

  • With treatment, however, many do eventually resume increased activities

  • Progressive or objective findings do not develop


Cheng  CA  et ...

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