Fibromyalgia

Disease Description (Causes and Symptoms)

• Definition summary: Fibromyalgia is a chronic pain syndrome in which chronic widespread pain, fatigue, sleep disturbances, and cognitive impairment persist for 3 months or longer without specific tissue damage. It is common in middle-aged people (mainly ages 30–50), with a higher incidence in women than in men (female predominance, approximately 9:1, depending on the report).

• Causes and pathophysiology: No single exact cause is known, and genetic predisposition and acquired factors act together. Abnormal pain processing due to central sensitization, imbalances in neurotransmitters (serotonin, norepinephrine, substance P, etc.), autonomic nervous system dysfunction, and stress, infection, trauma, and endocrine abnormalities are associated with the condition. Risk increases in people with a family history (an increased risk of disease has been reported among siblings).

• Main symptoms:

  • Widespread pain (mainly in the neck, shoulders, back, and lower back); tender points are a supporting diagnostic factor
  • Chronic fatigue and generalized stiffness
  • Sleep disturbances (reduced deep sleep and lack of refreshment)
  • Cognitive impairment (reduced attention and memory; the so-called “fibro fog”)
  • Autonomic and gastrointestinal symptoms: abdominal pain, abdominal discomfort, constipation, diarrhea, etc.
  • Headaches (migraines), tingling and sensory abnormalities, depression, and anxiety

• Diagnostic summary: Clinical diagnosis (ACR criteria: based on the widespread pain index (WPI) and symptom severity (SS) scale)—there is no specific diagnostic test. Blood tests, imaging tests, and other examinations may be performed for differential diagnosis.

Treatment Methods

• Treatment principles: The goals are symptom relief and improved functioning through education and self-management, regular exercise, and a multidisciplinary approach (medication plus nonmedication treatment). The focus is on symptom control and improving quality of life rather than a cure.
• Nonmedication treatment (recommended as first-line treatment)
  • Patient education: Explain the chronic nature of the disease and the absence of irreversible structural damage, and adjust expectations
  • Exercise therapy: Low-intensity aerobic exercise (walking, swimming, cycling), stretching, strength training, and gradual increases in activity—symptoms may worsen initially, but gradual continuation is recommended
  • Cognitive behavioral therapy (CBT), psychotherapy, sleep hygiene, relaxation techniques, meditation and yoga, aquatic exercise, and physical therapy
  • Adjunctive therapies: Acupuncture, massage, heat therapy, and other treatments may relieve symptoms in some patients
• Medication treatment (individualized)
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs): duloxetine and milnacipran—used to improve pain, depression, and functioning
  • Anticonvulsants (gabapentinoids): pregabalin and gabapentin—effective for improving pain and sleep
  • Tricyclic antidepressants (low-dose amitriptyline): used to improve sleep and relieve pain
  • General analgesics: Acetaminophen and NSAIDs may be used for certain types of pain, but their effectiveness is limited
  • Opioids: Generally not recommended (long-term risks and effectiveness are uncertain)
  • Local treatment: Limited local injections into tender points, etc.
• Procedures/surgery: There is no surgical treatment for fibromyalgia itself. If an associated lesion (for example, structural spinal disease) is present, it is treated separately.
• Precautions (during treatment)
  • Increase or decrease medications slowly; watch for side effects (dizziness, drowsiness, weight changes, gastrointestinal symptoms, etc.)
  • Avoid overexertion when starting exercise—establish a gradual plan
  • Actively assess and treat coexisting depression, anxiety, and sleep disturbances
  • Avoid long-term use of opioids and benzodiazepines whenever possible
• Risk of complications: Reduced functioning, depression and anxiety, social and occupational impairment, and increased healthcare utilization
• Prognosis: The condition follows a chronic course, with repeated improvement and worsening. Appropriate multimodal treatment can improve symptoms and functioning. It has little effect on life expectancy.

Outpatient Visit Checklist (Including Preparation Items and Sample Questions)

• Items to bring
  • List of current medications and supplements (including doses and administration times)
  • Copies of previous diagnoses and test results (blood tests and imaging)
  • Symptom diary: Record the location, intensity (numerical rating scale), and frequency of pain; sleep patterns; fatigue level; and triggers and aggravating factors (over the past few weeks)
  • Changes in daily functioning (ability to perform work and household tasks), and a check for depression and anxiety (a brief questionnaire may be used)
  • Treatments you have tried and their effects (exercise, medication, physical therapy, etc.)
• Helpful preparation for an outpatient visit
  • Pain map (mark the areas on a diagram), and a history of recent stress, infection, or trauma
  • Sleep patterns (bedtime, wake-up time, nighttime awakenings, etc.)
• Key information to report to the doctor during the visit
  • When the pain began and how it has progressed; pain patterns (widespread or localized); medication effects and side effects
  • Sleep quality, depression and suicidal thoughts, and the degree of difficulty in daily life

Examples of General Questions to Ask the Doctor

• What are the expected effects and possible side effects of this medication (or treatment)?
• How long should I take the medication? How should I stop taking it?
• Which nonmedication treatments (exercise or therapy) should be prioritized for relieving my pain?
• Should depression, anxiety, and sleep problems also be treated? Which specialist should I be referred to?
• What should I be careful about in daily life (exercise, work duties, and sleep habits)?

Examples of Condition-Specific Questions (1–2)

• Considering my symptoms (for example, the main areas of pain, sleep patterns, and depressive symptoms), which medication would be more suitable for me: duloxetine or pregabalin? (Mention any other medications you are taking or underlying conditions.)
• When starting exercise, what type, intensity, and frequency should I begin with so that I can continue without worsening the pain? Can you provide specific weekly goals?

(If necessary, blood tests or imaging tests may be ordered to assess diagnostic criteria (WPI/SS scales), screen for depression and sleep problems, and differentiate other diseases. Consultation with a multidisciplinary team (rheumatology, pain medicine, mental health, physical therapy, etc.) may be helpful.)