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Key points
- Fibromyalgia: chronic disorder with widespread musculoskeletal pain, fatigue, sleep issues, and cognitive/mood disturbances; affects ~2% globally, common in 30-50 years, F:M ratio ~3:1.
- Aetiology: linked to central sensitisation (amplified CNS response); nociplastic pain with hypersensitivity to mechanical stimulation.
- Risk factors: family history (8x risk in first-degree relatives), early adverse events, infections, trauma, and chronic comorbidities (e.g. RA, SLE).
- Symptoms: persistent, widespread dull ache, tender points, fatigue, morning stiffness, cognitive issues (“fibro fog”), IBS, environmental sensitivity.
- Investigations: exclude other conditions via FBC, ESR/CRP, TSH, RF, autoimmune screen; no specific imaging for diagnosis.
- Diagnosis: ACR criteria (pain in ≥4/5 regions for ≥3 months, WPI ≥7 + SSS ≥5 or WPI 4-6 + SSS ≥9); not a diagnosis of exclusion.
- Management: non-pharmacological first-line (CBT, exercise, physiotherapy, sleep hygiene); off-label antidepressants (amitriptyline, duloxetine) for pain/psychological distress.
- Complications: cognitive dysfunction, depression, reduced physical activity, chronic headaches, IBS, and skin issues.
Introduction
Fibromyalgia syndrome (FMS) is a chronic disorder characterised by widespread musculoskeletal pain, often accompanied by fatigue, sleep disturbances, cognitive dysfunction, and mood disturbances.1
It is classified in ICD-11 as a type of chronic primary pain and is considered part of the broader group of central sensitivity syndromes.
The pain in FMS is described as nociplastic, which refers to pain that is “more widespread or intense, or both, than would be expected given the amount of identifiable tissue or nerve damage”.3 This type of pain is often associated with additional symptoms such as fatigue, sleep problems, and mood or memory disturbances.3
Fibromyalgia affects approximately 2% of the global population, with prevalence increasing during middle age (50-59 years) and declining in older adults (80+ years).
The average age of onset is between 30 and 50 years, with a female-to-male ratio of approximately 3:1 in studies that do not use tender points as a criterion.4
Aetiology
The physiological hallmark of FMS is central sensitisation, a phenomenon in which the central nervous system (CNS) exhibits an amplified response to sensory input. Clinically, this can be identified through diffuse tenderness to palpation.
Central sensitisation is an umbrella term encompassing various dysfunctions in ascending and descending neural pathways, resulting in heightened sensitivity to mechanical stimulation.
This amplified CNS signalling underpins many symptoms associated with FMS, including widespread pain and sensitivity to touch.5
Risk factors
Risk factors for fibromyalgia include:
- Family history of chronic pain: the first-degree relatives of FM patients are 8 times as likely to have this condition6
- Environmental factors (stressors): early lifetime adverse events, medical illnesses (including infections), trauma, psychosocial stressors
Fibromyalgia is also commonly seen as a comorbidity in other chronic pain conditions such as osteoarthritis, rheumatoid arthritis, and systemic lupus erythematosus.
Clinical features
Fibromyalgia has a broad range of clinical features that can differ from person to person.
History
Typical symptoms of fibromyalgia include:
- Widespread pain: the defining symptom, typically described as a persistent, dull ache affecting both sides of the body, above and below the waist
- Tender points: 18 specific areas sensitive to touch or pressure, historically used in diagnosis, though modern criteria are less reliant on this
- Fatigue and sleep disturbances: difficulty falling or staying asleep, often accompanied by non-restorative sleep, leaving patients feeling unrefreshed
- Musculoskeletal stiffness: predominantly in the morning, improving throughout the day and unresponsive to corticosteroids (unlike other conditions)
- Cognitive difficulties: issues with memory, concentration, and cognitive tasks
- Irritable bowel syndrome (IBS): symptoms such as bloating, constipation, diarrhoea, and abdominal discomfort frequently co-occur
- Environmental sensitivity: heightened intolerance to bright lights, loud noises, strong odours, and cold, possibly linked to central sensitisation
Clinical examination
Most of the features are elicited from the history. However, relevant clinical examinations may include:
- Tender point exam: may provide valuable information about the overall status of the patient’s condition and support a diagnosis of fibromyalgia
- Self-reported questionnaires: useful for screening for cognitive dysfunction in patients with FM, but full neuropsychological testing may be required
Differential diagnoses
It is essential to consider other differential diagnoses, as numerous conditions can mimic fibromyalgia.
Important differential diagnoses to consider include:
- Rheumatoid arthritis (RA): an autoimmune disease causing joint stiffness, pain, and swelling. Unlike fibromyalgia, RA pain is typically localised to specific joints and is associated with inflammation, visible on clinical examination and confirmed by blood tests (e.g. elevated inflammatory markers or rheumatoid factor).
- Systemic lupus erythematosus (SLE): another autoimmune condition that can cause widespread pain, fatigue, and cognitive issues. However, SLE often involves additional systemic features such as skin rashes (e.g. butterfly rash), kidney involvement, and respiratory symptoms, which are not seen in fibromyalgia.
- Multiple sclerosis (MS): a neurological disorder with many symptoms, including muscle weakness, coordination problems, and sensory disturbances (e.g. numbness or tingling). While MS can share fatigue and pain with fibromyalgia, distinctive features like visual disturbances (optic neuritis) and objective neurological findings on imaging (e.g. MRI) help distinguish it.
- Chronic fatigue syndrome (CFS): characterised by profound, unrelenting fatigue not alleviated by rest. Shared symptoms with fibromyalgia include cognitive dysfunction, muscle pain, and headaches, but CFS often lacks the widespread pain and tender points typical of fibromyalgia7
Investigations
Laboratory investigations
Laboratory investigations are used to exclude other potential diagnoses.
Relevant laboratory investigations include:
- Full blood count
- Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
- Creatine kinase (CK)
- Liver function tests (LFT)
- Thyroid-stimulating hormone (TSH)
- HbA1c
- Urea and electrolytes (U&Es)
- Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP)
- Autoimmune screen
Imaging
No imaging investigations are helpful when diagnosing fibromyalgia.2
Diagnosis
The diagnosis of fibromyalgia can take more than 2 years, with patients seeing an average of 3.7 different doctors during that time.10
FMS is not a diagnosis of exclusion. The symptoms can also appear in other conditions and coexist with other medical conditions (e.g. rheumatoid arthritis).
The American College of Rheumatologists (ACR) 2016 diagnostic criteria can help clinicians decide more accurately whether to diagnose fibromyalgia.5
ACR diagnostic criteria for fibromyalgia
The following criteria are required:
- Generalised pain, defined as pain in at least 4 of 5 regions
- Symptoms have been 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
The Royal College of Physicians has a diagnostic worksheet for calculating the widespread pain index (WPI) and symptom severity scale (SSS).
Management
Effective management of fibromyalgia requires a patient-centred approach.
It is important to assess the patient’s understanding of their condition and that of their family, caregivers, and close friends. Educating and involving the patient’s support network can significantly help their ability to understand and manage the condition.
Non-pharmacological interventions are recommended as the first-line treatment for fibromyalgia.7
Non-pharmacological management
Self-management advice
- Structured exercise programmes
- Signposting to websites (e.g. British Pain Society, Pain Tool Kit, Live well with pain)
- Keeping a pain diary and thinking of ways to manage flares of pain
Health promotion
- Promoting a healthy, balanced diet
- Advice about alcohol and drug use
- Smoking cessation advice
Physiotherapy
- Massage therapy, myofascial release
- Acupuncture
- Transcutaneous electrical nerve stimulation (TENS)
- Exercises
Psychological interventions
- Cognitive behavioural therapy (CBT)
- Acceptance and commitment therapy (ACT)
- Support groups
Sleep management
- Sleep hygiene advice
Pain management programmes can also be helpful. Patients may require referral to secondary care pain specialist teams.
Pharmacological management
The European Medicines Agency has not approved any specific medications for the treatment of fibromyalgia.8
In adults aged 18 and over, antidepressants such as amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine, or sertraline may be prescribed “off-label.” This should follow a thorough discussion with the patient about potential side effects, risks, benefits, and interactions with other medications.8
Antidepressants can help manage fibromyalgia-related pain and psychological distress and may also improve sleep quality.
There is limited evidence supporting the use of NSAIDs, opioids, or other pain medications in chronic primary pain, including fibromyalgia.8
It is essential to review these treatments and assess their continued use. If a benefit is reported, a plan for ongoing use can be made. However, if the benefit is minimal, reducing and discontinuing these medications should be considered.8
Complications
Fibromyalgia can lead to a wide range of complications that affect various aspects of a person’s life, including:
- Cognitive difficulties: patients may experience trouble concentrating, memory issues, and mental cloudiness (“brain fog”)
- Mental health conditions: depression and anxiety are common and can significantly reduce quality of life
- Dermatological symptoms: skin conditions such as rashes and itching are frequently reported in fibromyalgia patients
- Reduced physical activity: chronic pain and fatigue may lead to decreased physical activity, potentially contributing to secondary health problems and increased cardiovascular risk
- Chronic headaches: recurrent headaches, including migraines, are prevalent
- Gastrointestinal problems: conditions such as irritable bowel syndrome (IBS) and acid reflux are often associated with fibromyalgia
Reviewer
Dr Franco Camilleri Vassallo
MD, FRCP (Lond), FRCP (Edin), FRCP (Glas)
References
- Bair MJ, Krebs EE. Fibromyalgia. Annals of Internal Medicine, 172(5). 2020. Available from: [LINK]
- Royal College of Physicians. The diagnosis of fibromyalgia syndrome. UK clinical guidelines London: RCP. 2022. Available from: [LINK]
- Fitzcharles, MA, Cohen SP, Clauw DJ, et al. Nociplastic pain: Towards an understanding of prevalent pain conditions. The Lancet, 397(10289), pp. 2098. 2021. Available from: [LINK]
- Queiroz LP. Worldwide epidemiology of fibromyalgia. Current Pain and Headache Reports, 17(8). 2013. Available from: [LINK]
- Wolfe F, Clauw DJ, Fitzcharles MA, et al. 2016 revisions to the 2010/2011 fibromyalgia diagnostic criteria. Seminars in Arthritis and Rheumatism, 46(3). 2016. Available from: [LINK]
- Arnold LM, Bennett RM, Crofford LJ, et al. AAPT diagnostic criteria for fibromyalgia. The Journal of Pain, 20(6), pp. 611–628. 2019. Available from: [LINK]
- Yunus MB. Fibromyalgia and overlapping disorders: The unifying concept of central sensitivity syndromes. Seminars in Arthritis and Rheumatism, 36(6). 2007. Available from [LINK]
- Macfarlane GJ, Kronisch C, Dean LE, et al. Eular revised recommendations for the management of fibromyalgia. Annals of the Rheumatic Diseases, 76(2). 2016. Available from: [LINK]
- NICE. Chronic pain (primary and secondary) in over 16s: Assessment of all chronic pain and management of chronic primary pain. 2021. Available from: [LINK]
- Choy E, Perrot S, Leon T, et al. A patient survey of the impact of fibromyalgia and the journey to diagnosis. BMC Health Services Research, 10(1). 2010. Available from: [LINK]
Image references
- Figure 1. Jmarchn. Widespread Pain Index Areas. License: [CC BY-SA]
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