BEYOND PAIN AND TIREDNESS: MANAGEMENT OF FIBROMYALGIA
Faculty:
The following continuing medical education team members were involved in the initial planning, development, and review of this activity:
L. Austin Fredrickson, MD, FACP
L. Austin Fredrickson is an Associate Professor of Internal Medicine at Northeast Ohio Medical University, where he serves as core faculty and teaches diagnostics, therapeutics, clinical skills, and health humanities. He is board-certified in general internal medicine and practices rural primary care. 
Pamela Sardo, PharmD, BS
Pamela Sardo is a freelance medical writer, licensed pharmacist, and the founder/principal at Sardo Solutions. She received her BS from the University of Connecticut and a PharmD from the University of Rhode Island. Pam’s career spans many years in retail, clinics, hospitals, long-term care, Veterans Affairs, pharmaceutical manufacturing, and managed healthcare across broad therapeutic classes and disease states.
The following faculty members were involved in authoring and reviewing this activity:
Kimberly Valenta, MD
Kimberly Valenta is a freelance medical writer and editor. She studied chemistry at Mount Holyoke College and medicine at Northwestern University. After completing her anesthesiology residency, she joined the faculty at Stanford University, where she cared for patients and taught medical students and residents. In 2020, she transitioned to full-time writing and editing. She holds a certificate in medical writing and editing from the University of Chicago and is an active member of the American Medical Writers Association.
Anna Shurtleff Smith, MPH, BSN-RN
Anna Shurtleff Smith is a graduate of the University of North Texas Health Science Center, School of Public Health, with a community health focus, and Texas Tech University School of Nursing. She has clinical experience in both inpatient and outpatient settings. Anna is passionate about patient education, health literacy, and health communications.
Topic Overview
Fibromyalgia is a central chronic pain syndrome that is characterized by increased pain perception, widespread pain in multiple areas of the body, fatigue, poor sleep quality, and cognitive disturbances. Fibromyalgia affects people of all ages but is mostly seen in adults, and there is no known cure. Despite a 2–4% global prevalence, it remains poorly understood and lacks consistent diagnostic criteria and management guidelines. This course discusses the attitudes of healthcare professionals toward fibromyalgia patients and how the disease typically presents, current theories on its pathophysiology, the suggested diagnostic workup, and recommendations for symptomatic management. This information can assist healthcare professionals in advocating for patients with fibromyalgia and in improving their health outcomes.
Accreditation Statements
In support of improving patient care, RxCe.com LLC is jointly accredited by the Accreditation CouncilTM for Continuing Medical Education (ACCME®), the Accreditation Council for Pharmacy Education (ACPE®), and the American Nurses Credentialing Center (ANCC®), to provide continuing education for the healthcare team.
This activity was planned by and for the healthcare team, and learners will receive 2 Interprofessional Continuing Education (IPCE) credits for learning and change.
Joint Universal Activity Number: The Joint Accreditation Universal Activity Numbers assigned to this activity are as follows:
Pharmacists: JA4008424-0000-26-017-H01-P
Pharmacy Technicians: JA4008424-0000-26-017-H01-T
Credits: 2 contact hour(s) (0.2 CEU(s)) of continuing education credit.
Credit Types:
IPCE Credits - 2 Credits
AAPA Category 1 Credit™️ - 2 Credits
AMA PRA Category 1 Credit™️ - 2 Credits
Pharmacy - 2 Credits
Type of Activity: Knowledge
Media: Computer-Based Training (i.e., online courses)
Estimated time to complete activity: 2 contact hour(s) (0.2 CEU(s)), including Course Test and course evaluation.
Release Date: February 7, 2026 Expiration Date: February 7, 2029
Target Audience: This educational activity is for Physicians, Physician Assistants, Pharmacists, and Pharmacy Technicians
How to Earn Credit: From February 7, 2026, through February 7, 2029, participants must:
Read the “learning objectives” and “author and planning team disclosures;”
Study the section entitled “educational activity;” and
Complete the Course Test and Evaluation form. The Course Test will be graded automatically. Following successful completion of the Course Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)
CME Credit: Credit for this course will be uploaded to CPE Monitor® for pharmacists. Physicians may receive AMA PRA Category 1 Credit™ and use these credits toward Maintenance of Certification (MOC) requirements. Physician Assistants may earn AAPA Category 1 CME credit, reportable through PA Portfolio. All learners should verify their individual licensing board's specific requirements and eligibility criteria.
Learning Objectives: Upon completion of this educational activity, participants should be able to:
Describe the role of central sensitization in fibromyalgia
Recognize the core clinical features and associated symptoms of fibromyalgia
Select appropriate multimodal treatment strategies for fibromyalgia
Develop a collaborative, multidisciplinary plan of care for patients with fibromyalgia
Disclosures
The following individuals were involved in planning, developing, and/or authoring this activity: L. Austin Fredrickson, MD, FACP; Kimberly Valenta, MD; Anna Shurtleff Smith, MPH, BSN-RN; and Pamela Sardo, PharmD, BS. None of the individuals involved in developing this activity has a conflict of interest or financial relationships related to the subject matter. There are no financial relationships or commercial or financial support relevant to this activity to report or disclose by RxCe.com or any of the individuals involved in the development of this activity.
© RxCe.com LLC 2026: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.
Educational Activity
Beyond Pain and Tiredness: Management of Fibromyalgia
Introduction
Fibromyalgia is a chronic pain syndrome characterized by increased pain perception, widespread musculoskeletal pain, fatigue, sleep disturbance, and cognitive symptoms. Many patients also experience stiffness, mood disorders, anxiety, depression, and functional impairment that interferes with daily activities.1
Fibromyalgia is considered a disorder of pain regulation involving central sensitization, in which altered processing within the central nervous system amplifies pain and sensory input. Although the precise pathophysiology is not fully understood and no curative therapy exists, symptoms can often be improved through a multimodal management approach.2
This course reviews common clinical presentations of fibromyalgia, current concepts in pathophysiology, diagnostic considerations, and evidence-based pharmacologic and nonpharmacologic management strategies. It also addresses clinician attitudes toward fibromyalgia and their impact on patient care. This information is intended to help health care professionals recognize fibromyalgia, validate patients' experiences, and partner with patients to improve symptom control and functional outcomes.
Clinician and Patient Attitudes Toward Fibromyalgia
With an incomplete understanding of fibromyalgia, clinicians' attitudes toward patients with fibromyalgia are not always supportive.3,4 This uncertainty may contribute to strained therapeutic relationships, in which some patients engage in maladaptive or counterproductive coping behaviors.3 These behaviors can, in turn, increase clinician frustration and reinforce perceptions that patients are unwilling or unable to help themselves. This dynamic has been described as “fibroism” and is supported by studies examining health care professionals’ attitudes towards fibromyalgia.3,5
A 2012 survey of 1,622 experienced physicians in Europe, Mexico, and South Korea reported that more than half felt their training in fibromyalgia was inadequate and that they found the condition difficult to diagnose.5 Approximately one-third of respondents did not feel confident in their ability to develop a treatment plan and reported insufficient knowledge about fibromyalgia.5
Earlier studies similarly identified negative clinician perspectives.3 In a 2010 Canadian study, 23% of general practitioners considered patients with fibromyalgia to be malingerers (i.e., individuals perceived as intentionally exaggerating or feigning symptoms), and 76% described managing fibromyalgia as time-consuming and frustrating.3
Although one might expect clinician attitudes to have improved over time, a 2023 qualitative evidence synthesis confirmed that challenges in diagnosis, management, and patient–clinician relationships persist.6 In that review, 38% of patients reported delaying medical care because they feared their symptoms would not be taken seriously.6 More recent work suggests that clinician attitudes towards fibromyalgia are heterogeneous and influenced by factors such as clinical experience, training, and confidence in management strategies.7
Delays in diagnosis and a lack of validation contribute to increased health care utilization, unnecessary testing and treatments, emotional distress, loss of trust in the health care system, and strained personal and professional relationships.8 In addition, a lack of validation by health care professionals may contribute to greater pain severity and symptom burden.8
There is no cure for fibromyalgia, and management therefore focuses on symptom control.6 Multidisciplinary and patient-centered approaches have been shown to reduce symptoms and improve functional outcomes.4
Symptoms of Fibromyalgia
The hallmark symptoms of fibromyalgia are persistent and widespread noninflammatory musculoskeletal pain, fatigue, impaired cognitive function, and nonrestorative sleep.9,10 Additional symptoms are common and may include migraine or tension-type headache, digestive symptoms such as irritable bowel syndrome, morning stiffness, and irritable or overactive bladder. Individuals may also demonstrate a negative affect defined as a tendency toward persistent negative mood states, including catastrophizing, anxiety, neuroticism, and depression.9,10
Pain in fibromyalgia is persistent, lasting longer than three months, and widespread, affecting at least four of five body regions.9,10 Musculoskeletal pain involving the shoulders, arms, lower back, buttocks, and thighs is typical. Pain is often described as throbbing or aching. Affected areas are frequently tender and hypersensitive, a phenomenon known as hyperalgesia, and pain may be provoked by normally nonpainful stimuli, such as light touch or pressure, referred to as allodynia.6 The pain cannot be explained by tissue injury or inflammation and is thought to result from altered central sensory processing.9,10
Clinical presentation can be complicated by pain from coexisting conditions, including arthritis, migraine, and irritable bowel syndrome. Medical terms commonly used to describe the pain in fibromyalgia include the following:10
Allodynia: Pain resulting from a normally non-noxious stimulus to intact skin (e.g., pain caused by a blood pressure cuff)
Hyperalgesia: An abnormally increased pain response to a noxious stimulus (e.g., exaggerated pain response to a fingerstick)
Somatic pain: Pain arising from the body wall, including skin, muscles, joints, bones, or connective tissues, that is typically well localized and described as aching or throbbing
Visceral pain: Pain originating from internal organs within a body cavity that is more difficult to localize and often described as colicky or squeezing
Individuals with fibromyalgia commonly report physical and emotional fatigue that is disproportionate to activity level and not relieved by rest or sleep. They may also experience increased sensitivity to environmental stimuli, including light and sound.
Impaired cognitive function, including memory difficulties and decreased mental alertness, is frequently reported and is commonly referred to as “fibro fog.”11,12 These cognitive symptoms may contribute to anxiety and depression and can interfere with daily functioning. For many individuals, fibro fog is among the most debilitating symptoms of fibromyalgia.1
Nonrestorative sleep is another common feature of fibromyalgia.1 Individuals often report sleeping fewer hours than recommended and awakening feeling stiff, weak, and unrefreshed.1
Symptoms of fibromyalgia are frequently exacerbated by physical and emotional stressors, including disrupted sleep and physical activity that exceeds an individual’s level of conditioning.1 Weather changes can also trigger symptoms.10 This constellation of symptoms is characteristic of central pain syndromes.
Central Sensitization to Pain and Fibromyalgia
Central sensitization to pain is characterized by increased pain perception and heightened sensitivity throughout the body.13 In fibromyalgia, pain occurs in the absence of identifiable tissue injury or inflammation and reflects altered processing within the central nervous system. The precise mechanisms underlying central sensitization are not fully understood.13
Fibromyalgia develops through a combination of patient-specific factors, including genetic predisposition, prior illness or injury, emotional and cognitive influences, and the ability to cope with physical and psychological stressors.14 As a result of persistent neural dysregulation, patients experience greater pain than would be expected based on peripheral nociceptive input.15 Alterations in central pain and sensory processing have been consistently demonstrated in individuals with fibromyalgia and may be triggered or exacerbated by infections, physical trauma, or emotional stress.14 Early and abnormal activation of pain pathways, together with impaired endogenous antinociceptive mechanisms, contribute to the persistence of clinical pain.4,12
Clinically, fibromyalgia is characterized by impaired pain modulation, leading to prolonged and amplified pain responses.13,15 Neurochemical alterations include elevated levels of excitatory neurotransmitters such as glutamate and substance P, along with reduced activity of pain-inhibiting systems involving serotonin and norepinephrine, dysregulation of dopamine, and alterations in endogenous opioid systems.13,15 These findings are consistent with impaired descending inhibitory pain control and increased central pain excitability.4
Serotonin and norepinephrine normally help the brain dampen pain signals, and reduced activity in these systems can lead to pain amplification in fibromyalgia.14 For this reason, medications that increase serotonin and norepinephrine signaling are commonly used in management.15 Emerging evidence also suggests that neuroinflammation, immune dysregulation, and small fiber neuropathy may contribute to symptoms in some patients, supporting an individualized approach to treatment.4
Epidemiology of Fibromyalgia
Fibromyalgia is generally estimated to have a worldwide prevalence of 2% to 4%, although this figure may be an underestimate because of challenges in diagnosis.9 Fibromyalgia is a clinical diagnosis without objective biomarkers, and reported prevalence varies depending on the diagnostic criteria used.10,16
Fibromyalgia is more prevalent in females than in males, although recent studies suggest that females account for no more than 60% of total cases.17 Given the historically high enrollment of White participants and underrepresentation of other racial or ethnic groups in fibromyalgia research, prevalence by race remains uncertain.16 Prevalence increases with age and appears to peak in the seventh decade of life.18
The first diagnostic criteria for fibromyalgia were published in 1990 by the American College of Rheumatology (ACR).18 The 1990 ACR criteria focused on pain symptoms and included two main requirements:18
A history of widespread pain for at least three months
Pain in at least 11 of 18 designated tender points on digital palpation using an approximate force of 4 kg
In 2010, the ACR updated its diagnostic criteria. The 2010 criteria eliminated tender point assessment and instead incorporated two scoring tools:10,18
The Widespread Pain Index (WPI), which counts the number of body regions in which the patient experienced pain over the previous week
The Symptom Severity Scale (SSS), which assesses the following symptoms:19
Fatigue
Waking unrefreshed
Cognitive symptoms
Somatic symptoms in general encompass a broad range of complaints, including gastrointestinal and genitourinary symptoms
In 2011, modifications to the 2010 criteria were proposed to more narrowly define somatic symptoms and to allow patients to self-administer the assessment.10,18 Under the modified 2010 criteria, somatic symptoms were limited to headaches, lower abdominal pain or cramps, and depression experienced within the previous six months.10,18
A 2015 UK study comparing the 1990, 2010, and modified 2010 criteria found substantial differences in estimated prevalence among 1,604 participants:18
1.7% using the ACR 1990 criteria, with a female-to-male ratio of 13.7:1
1.2% using the ACR 2010 criteria, with a female-to-male ratio of 4.8:1
5.4% using the modified 2010 criteria, with a female-to-male ratio of 2.3:1
The higher female prevalence observed with the 1990 criteria is thought to reflect the subjectivity of tender point assessment.14 The higher overall prevalence observed with the patient-administered modified 2010 criteria is believed to reflect increased symptom reporting when assessments are self-completed.10
In 2016, revised criteria were proposed that combined elements of the 2010 and modified 2010 criteria, allowing diagnostic assessment to be completed by either clinicians or patients. These criteria are widely used today.10 Current diagnostic frameworks do not explicitly incorporate psychological, environmental, or sociocultural factors, despite evidence that these factors influence disease onset, symptom experience, and management.10
In summary, fibromyalgia is diagnosed using clinical criteria that rely heavily on patient-reported symptoms and may be influenced by sociocultural norms. The evolution from the 1990 criteria to later versions reflects recognition of the condition's multifactorial nature by incorporating non-pain symptoms. However, some experts argue that additional factors should be integrated into future diagnostic frameworks. The perception of fibromyalgia as a condition that predominantly affects women may be overstated. Until more objective diagnostic tools with improved sensitivity and specificity are developed, the true prevalence of fibromyalgia will remain uncertain.
Fibromyalgia’s Clinical Presentation and Diagnostic Workup
Fibromyalgia can be challenging to diagnose because its initial presentation is often nonspecific.9,10 Symptoms such as forgetfulness, poor sleep, musculoskeletal pain, and fatigue overlap with many other conditions. Patients may also focus on pain in a single area during a clinic visit rather than report widespread pain, particularly early in the disease course.9,10 The presentation is often further complicated by additional symptoms such as nausea, urinary frequency, and headache, resulting in what clinicians may describe as a positive review of systems, reflecting widespread symptom reporting rather than multisystemic disease.
To diagnose fibromyalgia, clinicians must first consider it in the differential diagnosis.2 Identifying risk factors and associated conditions can prompt more targeted assessment for fibromyalgia. Risk factors associated with fibromyalgia include the following:1
A family history of the disease (first-degree relative)
Traumatic childhood experiences, including abuse, serious illness, or accidents
Prolonged psychological stress at home or work
Sleep disorders
Other conditions that may be present along with fibromyalgia include:
Psychiatric conditions:20
Major depressive disorder
Anxiety disorders
Borderline personality disorder
Obsessive-compulsive personality disorder
Post-traumatic stress disorder
Central sensitization-related pain conditions:21
Irritable bowel syndrome
Interstitial cystitis
Chronic fatigue syndrome
Tension-type or migraine headaches
Temporomandibular disorder
Gulf War Syndrome
Vulvodynia
Other chronic pain conditions:21
Ankylosing spondylitis
Osteoarthritis
Rheumatoid arthritis
Systemic lupus erythematosus
Diabetes mellitus
Inflammatory bowel disease
Endometriosis
Hypothyroidism
Diagnosing fibromyalgia does not typically require specialist referral and can usually be accomplished in the primary care setting using validated criteria.2 Clinicians may use the 2016 revisions to the 2010/2011 fibromyalgia diagnostic criteria. In cases of diagnostic uncertainty, referral to a rheumatologist, neurologist, or pain specialist may be appropriate. Diagnostic criteria for adults are summarized in Tables 1 through 3.22
Table 1
Diagnosing Fibromyalgia in Adults
| Fibromyalgia may be diagnosed in adults when all of the following criteria are met16 |
| âś“ Generalized pain, defined as pain in at least 4 of 5 body regions |
| âś“ Symptoms present at a similar level for at least 3 months |
| ✓ Widespread Pain Index (WPI) ≥ 7 and Symptom Severity Scale (SSS) score ≥ 5 OR WPI of 4–6 and SSS score ≥ 9 |
Table 2
Widespread Pain Index (WPI)
| Regions | Circle the areas where you’ve had pain: |
| Left upper region | Left jaw Left shoulder Left upper arm Left lower arm |
| Right upper region | Right jaw Right shoulder Right upper arm Right lower arm |
| Left lower region | Left hip Left upper leg Left lower leg |
| Right lower region | Right hip Right upper leg Right lower leg |
| Axial region | Neck Upper back Lower back Chest Abdomen |
| Total the number of circled areas | (Score out of 19) |
Table 3
Symptom Severity Scale
| Indicate the level of severity over the past week | No problem | Mild Problem | Moderate Problem | Severe Problem |
| Points | 0 | 1 | 2 | 3 |
| Fatigue | ⬜ | ⬜ | ⬜ | ⬜ |
| Waking unrefreshed | ⬜ | ⬜ | ⬜ | ⬜ |
| Trouble thinking or remembering | ⬜ | ⬜ | ⬜ | ⬜ |
| Indicate whether you’ve had any of these symptoms | Point = 0 | Point = 1 | ||
| Headache | ⬜No | ⬜Yes | ||
| Lower abdominal pain or cramps | ⬜No | ⬜Yes | ||
| Depression | ⬜No | ⬜Yes | ||
| Total all points (out of 12) | ||||
Fibromyalgia is not a diagnosis of exclusion. It frequently coexists with other chronic pain conditions, such as rheumatoid arthritis, systemic lupus erythematosus, and ankylosing spondylitis.2,9 Although physical examination, laboratory testing, and imaging are not required to diagnose fibromyalgia, they may be appropriate to evaluate alternative diagnoses when clinically indicated.
Additional diagnostic frameworks, including the modified 2019 Fibromyalgia Assessment Status (FAS) and Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks–American Pain Society Pain Taxonomy (AAPT) criteria, have been proposed.23 However, these tools demonstrate lower sensitivity, specificity, and overall diagnostic accuracy, and the 2016 criteria remain the most widely recommended.23
Diagnostic uncertainty may persist in some cases. Symptoms can fluctuate over time, resulting in scores below diagnostic thresholds, and comorbid conditions may complicate interpretation. Clinicians should openly discuss diagnostic uncertainty, review key symptoms to monitor, and agree on symptom-focused management strategies, even when a formal diagnosis has not yet been established.
Pharmacologic Management of Fibromyalgia
The American Pain Society and European League Against Rheumatism (EULAR) have published treatment recommendations for fibromyalgia.24 These recommendations include several classes of medications commonly used in management, including serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and antiepileptic drugs (AEDs).24,25 Evidence supporting the use of selective serotonin reuptake inhibitors (SSRIs) for pain relief is limited, and these agents are generally reserved for comorbid mood disorders rather than pain management.
The U.S. Food and Drug Administration (FDA) has approved duloxetine, pregabalin, and milnacipran for the treatment of fibromyalgia.26-28 Although these agents demonstrate modest, broadly similar efficacy for pain reduction, their effects on associated symptoms, such as sleep disturbance, fatigue, and mood, vary. Differences in pharmacologic profiles, adverse effects, and patient comorbidities support an individualized approach to medication selection and dose titration.2,28
Treatment of fibromyalgia should be multimodal and is most effective when pharmacologic therapy is combined with patient education, physical activity, and psychological interventions.14,29 Medications are best used as part of a symptom-based, stepwise approach, with shared decision-making and realistic goal setting.14 Pharmacologic therapy should be framed as supportive rather than curative, recognizing that complete symptom resolution is uncommon.
In some individuals, the effectiveness of pharmacologic therapy may diminish over time. When this occurs, medications should be tapered gradually and alternative therapies introduced cautiously. Finding an effective regimen often requires a trial-and-error approach, with close monitoring for benefit and adverse effects. Table 4 summarizes commonly prescribed pharmacologic agents used to manage fibromyalgia-related pain.
Table 4
Common Pharmacologic Agents Used to Manage Fibromyalgia Pain2
| Medication | Typical Dose* | Primary Role in Pain Management | Additional Symptom Benefits | Common Adverse Effects / Precautions |
| Duloxetine | 20–30 mg once daily initially; increase to 60 mg once daily as tolerated | Central pain modulation (SNRI) | May improve fatigue, mood, and functional status | Nausea, dry mouth, insomnia or somnolence, dizziness, increased bleeding risk, hepatotoxicity, suicidal ideation |
| Milnacipran | 12.5 mg once daily initially; titrate to 50 mg twice daily (maximum 200 mg/day) | Central pain modulation (SNRI) | May improve fatigue and physical function | Nausea, headache, constipation, increased heart rate and blood pressure, insomnia, suicidal ideation |
| Pregabalin | 25–50 mg at bedtime initially; titrate to 150–450 mg/day in divided doses | Reduces pain amplification and central sensitization | May improve sleep quality and reduce anxiety | Dizziness, somnolence, peripheral edema, weight gain, blurred vision, suicidal ideation |
| Amitriptyline†| 5–10 mg at bedtime initially; may increase to 20–30 mg nightly | Modulates pain perception (TCA) | Improves sleep; may reduce fatigue | Anticholinergic effects (dry mouth, constipation, urinary retention), orthostatic hypotension, sedation, confusion, QT prolongation |
| Cyclobenzaprine†| 5–10 mg at bedtime initially; may increase to 10–40 mg/day in 1–3 divided doses | Reduces pain and muscle tension (tricyclic derivative) | Improves sleep quality | Sedation, dizziness, dry mouth, confusion; avoid in older adults |
| Gabapentin†| 100–300 mg at bedtime initially; titrate to 1200–2400 mg/day in divided doses | Reduces pain amplification | May improve sleep and anxiety | Dizziness, somnolence, peripheral edema, ataxia, weight gain, suicidal ideation |
* Lower starting doses than those specified in prescribing information are commonly used in clinical practice to improve tolerability, with gradual titration based on patient response and adverse effects.
†Not approved by the US Food and Drug Administration for the treatment of fibromyalgia
Individuals with fibromyalgia frequently self-medicate with over-the-counter analgesics, such as acetaminophen or nonsteroidal anti-inflammatory drugs, in an effort to relieve symptoms.29,30 These agents generally have limited effectiveness in fibromyalgia and should be used judiciously, with attention to comorbid conditions and potential drug interactions. Opioids are generally not recommended for the treatment of fibromyalgia, as they are typically ineffective and are associated with risks of dependence, tolerance, and poorer functional outcomes.29 Collaboration with a clinician experienced in managing fibromyalgia, such as a rheumatologist, physical medicine and rehabilitation specialist, neurologist, or pain specialist, may be appropriate in complex cases.
Pharmacy team members play an important role in monitoring for drug interactions, adverse effects, and adherence concerns in individuals with fibromyalgia. Ongoing counseling provides opportunities to reinforce expectations, address concerns, and support patients. Emphasis should be placed on taking medications exactly as prescribed and avoiding abrupt discontinuation without medical guidance.
Patients can be encouraged to report new or worsening symptoms after starting or adjusting medications. Clear communication regarding dosing, titration schedules, and anticipated adverse effects can help improve adherence and reduce treatment discontinuation.
Pharmacy technicians are often the first point of contact in the pharmacy setting and are well-positioned to identify prescription changes related to dose titration or tapering and to refer clinical questions to the pharmacist. Accurate prescription processing, verification of medication strength, and appropriate use of auxiliary labels, including warnings about sedation or dizziness, are critical. Given the frequency of comorbid conditions and polypharmacy in this population, vigilance for drug interaction alerts remains essential.
Nonpharmacologic Management and Interprofessional Collaboration
Nonpharmacologic management is a foundational component of fibromyalgia care and plays a central role in improving pain, function, and quality of life. Current guidelines emphasize the importance of lifestyle-based interventions, particularly exercise, supported by patient education and psychological therapies. These approaches are recommended for most individuals with fibromyalgia and are often most effective when combined with pharmacologic therapy.
Exercise therapy is strongly recommended for the management of fibromyalgia.31-33 Individuals should begin at a low intensity and gradually increase duration and intensity over time to minimize symptom exacerbation. Low-impact aerobic exercise and strength training have demonstrated consistent benefits.31-33 Suggested activities include walking, swimming, yoga, water-based exercises, cycling, dancing, resistance training using body weight or light weights, and other similar low-impact activities.31
Some patients may benefit from initial guidance from an exercise physiotherapist or physical therapist, particularly if pain, deconditioning, or fear of worsening symptoms limits participation. Strenuous or abrupt increases in activity may temporarily worsen symptoms. Ongoing encouragement and reinforcement are often needed to support adherence. Studies suggest that meaningful symptom improvement may be achieved with as little as 20 minutes of activity per session, two to three times per week.32
Patient education about fibromyalgia is another key component of nonpharmacologic management. Understanding fibromyalgia as a condition involving altered central pain processing can help patients contextualize their symptoms, communicate more effectively with others, and participate actively in self-management. Education has been associated with improved coping, increased engagement in recommended therapies, and greater confidence in managing symptoms. Participation in peer support groups, whether in person or online, may provide additional emotional support and practical strategies.
A variety of nonpharmacologic therapies have been studied, though the evidence varies. Cognitive-behavioral therapy (CBT), for example, has shown statistically significant improvements in pain and disability, but the effect has been modest and may not translate to clinically meaningful benefit for all patients.31 Similar limitations apply to other complementary and behavioral interventions, underscoring the importance of individualized care.
Responses to nonpharmacologic therapies vary, and patients should be encouraged to explore different options based on symptom burden, preferences, access, and cost. Reasonable options supported by varying levels of evidence include the following:34
Meditative movement therapies, such as tai chi, restorative yoga, and qigong
Psychological therapies, including CBT or other structured behavioral interventions
Sleep hygiene interventions or referral to a sleep specialist when sleep disturbance is prominent
Nutritional counseling with a registered dietician to address diet-related contributors to fatigue or overall health
Acupuncture performed by a qualified practitioner
Massage therapy from a provider familiar with fibromyalgia
Referral to a pain specialist for consideration of noninvasive neuromodulation techniques, such as transcranial electric stimulation or transcranial magnetic stimulation
Fibromyalgia is a chronic pain condition without a cure. Both pharmacologic and nonpharmacologic therapies can reduce symptom burden and improve function, but complete symptom resolution is uncommon. A collaborative, interprofessional approach that incorporates clinicians, therapists, pharmacists, and allied health professionals can help patients set realistic expectations, build self-efficacy, and sustain long-term management strategies.
Patient Case: Guided Clinical Reflection
A 42-year-old woman presents with a 3-year history of diffuse musculoskeletal pain, persistent fatigue, and nonrestorative sleep. Pain involves the shoulders, neck, lower back, hips, and thighs, and is present most days. Symptoms worsen with stress and poor sleep. She also reports difficulty concentrating (“brain fog”) and morning stiffness lasting more than one hour, without joint swelling.
Her medical history includes migraine headaches and irritable bowel syndrome. Over-the-counter acetaminophen and NSAIDs have provided minimal relief.
Which feature of this presentation most strongly supports fibromyalgia rather than an inflammatory rheumatologic disorder? a. Morning stiffness lasting more than one hour b. Diffuse pain involving multiple regions for more than 3 months c. Female sex d. History of migraine headaches |
The correct answer is b. Diffuse pain involving multiple regions for more than 3 months.
Fibromyalgia is defined by chronic, widespread pain affecting multiple regions of the body for at least three months. While morning stiffness may occur in fibromyalgia, prolonged stiffness alone is not specific and is also seen in inflammatory conditions. Female sex and comorbid migraine are common in fibromyalgia, but are not diagnostic features and cannot distinguish fibromyalgia from other disorders.
Physical examination reveals diffuse tenderness to light palpation over multiple muscle groups, without joint swelling, focal neurologic deficits, or muscle weakness. Laboratory testing, including CBC, TSH, ESR, and CRP, is within normal limits.
Which statement best describes the role of laboratory testing in suspected fibromyalgia? a. Abnormal inflammatory markers are required for diagnosis b. Testing is used primarily to confirm fibromyalgia c. Normal results help exclude alternative diagnoses d. Imaging is routinely required |
The correct answer is c. Normal results help exclude alternative diagnoses.
Fibromyalgia is a clinical diagnosis and does not require laboratory confirmation. Basic laboratory testing may be appropriate to evaluate for alternative causes of symptoms when clinically indicated. Normal inflammatory markers are typical in fibromyalgia and help reassure both clinicians and patients that inflammatory or systemic disease is unlikely.
Using the 2016 fibromyalgia diagnostic criteria, the patient meets criteria based on widespread pain, symptom duration, and elevated WPI and SSS scores. The clinician explains fibromyalgia as a disorder of altered central pain processing rather than ongoing tissue injury.
Which explanation is most likely to improve patient understanding and acceptance of a fibromyalgia diagnosis? a. Emphasizing the absence of structural disease b. Framing fibromyalgia as a disorder of central pain processing c. Avoiding discussion of chronicity d. Reassuring the patient that symptoms will resolve with medication |
The correct answer is b. Framing fibromyalgia as a disorder of central pain processing.
Explaining fibromyalgia in terms of altered central pain processing validates the patient’s symptoms while helping them understand why imaging and laboratory tests may be normal. This framing supports engagement in multimodal treatment and avoids minimizing symptoms. Avoiding discussion of chronicity or implying complete symptom resolution can undermine trust and set unrealistic expectations.
A shared management plan is developed that includes patient education, gradual initiation of low-impact exercise, sleep optimization, and discussion of pharmacologic options targeted to the patient’s most bothersome symptoms.
Which approach best reflects current recommendations for fibromyalgia management? a. Pharmacologic therapy alone b. Early opioid therapy for pain control c. Multimodal treatment with realistic goals d. Diagnostic reassurance without active treatment |
The correct answer is c. Multimodal treatment with realistic goals.
Current guidelines emphasize a multimodal approach that combines nonpharmacologic and pharmacologic strategies, individualized to patient symptoms and preferences. Opioids are not recommended, and pharmacologic therapy alone is unlikely to address the full symptom burden of fibromyalgia. Education and reassurance are important, but should be paired with active management strategies.
Summary and What is Next
A cure or single definitive treatment for fibromyalgia remains elusive. The condition is characterized by a broad range of symptoms, and both pain severity and physical function can be significantly affected. Psychological factors such as anxiety, stress, and depression commonly coexist with fibromyalgia and may exacerbate symptom burden.
Ongoing research continues to refine our understanding of fibromyalgia pathophysiology and symptom variability. Given that an estimated 65% to 99% of individuals with fibromyalgia experience sleep disturbances, one current study is examining the relationship between central sensitization chronotype (preferred sleep timing), pain intensity, disability, and quality of life.35
Another clinical trial is evaluating the effects of metformin, administered as 500 mg once daily, compared with placebo, on hyperalgesia and other fibromyalgia-related symptoms.36 These studies reflect continued efforts to better characterize symptom drivers and identify potential adjunctive treatment strategies.
Individuals living with fibromyalgia often experience substantial physical, emotional, and functional challenges. Participation within an interprofessional care team supports comprehensive, multidisciplinary management by reinforcing education, monitoring therapy, addressing adverse effects, and supporting adherence. This collaborative approach plays an important role in optimizing outcomes for patients with fibromyalgia.
Course Test
A patient presents with chronic widespread musculoskeletal pain, fatigue, and nonrestorative sleep. Laboratory testing is normal. Which finding most strongly supports a diagnosis of fibromyalgia?
Morning stiffness lasting more than one hour
Pain confined to a single anatomic region
Widespread pain involving multiple body regions for more than 3 months
Progressive muscle weakness
Which clinical feature would make fibromyalgia less likely and prompt further evaluation for an alternative diagnosis?
Cognitive complaints (“fibro fog”)
Diffuse tenderness to light palpation
Objective joint swelling and warmth
Fluctuating symptom severity
Fibromyalgia is best described as a condition involving which underlying mechanism?
Persistent peripheral tissue inflammation
Structural damage to muscles and joints
Altered central nervous system pain processing
Progressive neuromuscular degeneration
Which comorbidity is most commonly associated with fibromyalgia and other central sensitization–related conditions?
Rheumatoid arthritis
Irritable bowel syndrome
Myasthenia gravis
Peripheral vascular disease
What is the primary purpose of laboratory testing in patients with suspected fibromyalgia?
To confirm the diagnosis
To identify disease-specific biomarkers
To rule out alternative diagnoses when indicated
To monitor disease severity over time
Which nonpharmacologic intervention has the strongest evidence for improving pain and function in fibromyalgia?
Complete rest and activity avoidance
Low-impact aerobic exercise with gradual progression
Passive modalities alone (e.g., massage only)
High-intensity resistance training
When counseling a patient newly diagnosed with fibromyalgia, which message is most consistent with current guidelines?
Symptoms typically resolve with medication
Fibromyalgia reflects ongoing tissue damage
A multimodal approach can improve symptoms and function
Physical activity should be avoided during flares
Which statement best reflects appropriate expectations for pharmacologic therapy in fibromyalgia?
Medications typically eliminate pain
Medications are ineffective and should be avoided
Medications may reduce symptoms as part of a broader treatment plan
Opioids are preferred for moderate to severe pain
Which medication is approved by the U.S. Food and Drug Administration (FDA) for the treatment of fibromyalgia?
Amitriptyline
Gabapentin
Duloxetine
Cyclobenzaprine
Which statement best reflects the role of interprofessional care in fibromyalgia management?
Care is most effective when directed by a single specialist
Interprofessional collaboration supports education, adherence, and functional goals
Multiple providers increase confusion and delay care
Nonpharmacologic care should be deferred until medications fail
References
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