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Therapy Insight: fibromyalgia—a different type of pain needing a different type of treatment

Nature Clinical Practice Rheumatology volume 2, pages 364–372 (2006)Cite this article

Abstract

In the past decade, we have made tremendous progress in our understanding of fibromyalgia, which is now recognized as one of many 'central' pain syndromes that are common in the general population. Specific genes that might confer an increased risk of developing fibromyalgia syndrome are beginning to be identified and the environment (in this case exposure to stressors) might also have a significant effect on triggering the expression of symptoms. After developing the syndrome, the hallmark aberration noted in individuals with fibromyalgia is augmented central pain processing. Insights from research suggest that fibromyalgia and related syndromes require a multimodal management program that is different from the standard used to treat peripheral pain (i.e. acute or inflammatory pain). Instead of the nonsteroidal anti-inflammatory drugs and opioids commonly used in the treatment of peripheral pain, the recommended drugs for central pain conditions are neuroactive compounds that downregulate sensory processing. The most efficacious compounds that are currently available include the tricyclic drugs and mixed reuptake inhibitors that simultaneously increase serotonin and norepinephrine concentrations in the central nervous system. Other compounds that increase levels of single monoamines (serotonin, norepinephrine or dopamine), and anticonvulsants also show efficacy in this condition. In addition to these pharmacologic therapies, which are useful in improving symptoms, nonpharmacologic therapies such as exercise and cognitive behavioral therapy are useful treatments for restoring function to an individual with fibromyalgia.

Key Points

  • Fibromyalgia syndrome overlaps with a number of systemic and regional chronic pain and abnormal sensory conditions that share mechanisms and effective treatments

  • Population-based studies suggest that chronic widespread pain (fibromyalgia without the misconceived clinical reliance on tender points) is only slightly more common in women than men, and only modestly associated with distress

  • Aberrant pain and sensory processing caused by spinal and supraspinal alterations is the most consistently detected abnormality in fibromyalgia syndrome

  • Neuroactive compounds, especially those that raise central levels of norepinephrine and serotonin, are effective in improving the symptoms of fibromyalgia syndrome and should be first-line therapy

  • Exercise and cognitive behavioral therapy are effective and essential in the treatment of fibromyalgia syndrome

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Figure 1: Central pain syndromes that have symptoms overlapping with those of fibromyalgia syndrome
Figure 2: Treatments to break the cycle of worsening symptoms of fibromyalgia
Figure 3: Subsets of fibromyalgia patients

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References

  1. Wolfe F et al. (1990) The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 33: 160–172

    Article  CAS  Google Scholar 

  2. Wolfe F et al. (1995) Aspects of fibromyalgia in the general population: sex, pain threshold, and fibromyalgia symptoms. J Rheumatol 22: 151–156

    CAS  PubMed  Google Scholar 

  3. Croft P et al. (1993) The prevalence of chronic widespread pain in the general population. J Rheumatol 20: 710–713

    CAS  PubMed  Google Scholar 

  4. Wolfe F et al. (1995) The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum 38: 19–28

    Article  CAS  Google Scholar 

  5. Croft P et al. (1994) Population study of tender point counts and pain as evidence of fibromyalgia. Br Med J 309: 696–699

    Article  CAS  Google Scholar 

  6. Petzke F et al. (2001) Dolorimetry performed at 3 paired tender points highly predicts overall tenderness. J Rheumatol 28: 2568–2569

    CAS  PubMed  Google Scholar 

  7. Granges G and Littlejohn G (1993) Pressure pain threshold in pain-free subjects, in patients with chronic regional pain syndromes, and in patients with fibromyalgia syndrome. Arthritis Rheum 36: 642–646

    Article  CAS  Google Scholar 

  8. Wolfe F (1997) The relation between tender points and fibromyalgia symptom variables: evidence that fibromyalgia is not a discrete disorder in the clinic. Ann Rheum Dis 56: 268–271

    Article  CAS  Google Scholar 

  9. Petzke F et al. (1999) Pain sensitivity in patients with fibromyalgia (FM): Expectancy effects on pain measurements. Arthritis Rheum 42: S342

    Google Scholar 

  10. Croft P et al. (1996) More pain, more tender points: is fibromyalgia just one end of a continuous spectrum? Ann Rheum Dis 55: 482–485

    Article  CAS  Google Scholar 

  11. Papageorgiou AC et al. (2002) Chronic widespread pain in the population: a seven year follow up study. Ann Rheum Dis 61: 1071–1074

    Article  CAS  Google Scholar 

  12. Arnold LM et al. (2004) Family study of fibromyalgia. Arthritis Rheum 50: 944–952

    Article  Google Scholar 

  13. Bondy B et al. (1999) The T102C polymorphism of the 5-HT2A-receptor gene in fibromyalgia. Neurobiol Dis 6: 433–439

    Article  CAS  Google Scholar 

  14. Offenbaecher M et al. (1999) Possible association of fibromyalgia with a polymorphism in the serotonin transporter gene regulatory region. Arthritis Rheum 42: 2482–2488

    Article  CAS  Google Scholar 

  15. Buskila D et al. (2004) An association between fibromyalgia and the dopamine D4 receptor exon III repeat polymorphism and relationship to novelty seeking personality traits. Mol Psychiatry 9: 730–731

    Article  CAS  Google Scholar 

  16. Clauw DJ and Chrousos GP (1997) Chronic pain and fatigue syndromes: overlapping clinical and neuroendocrine features and potential pathogenic mechanisms. Neuroimmunomodulation 4: 134–153

    Article  CAS  Google Scholar 

  17. Crofford LJ et al. (1994) Hypothalamic–pituitary–adrenal axis perturbations in patients with fibromyalgia. Arthritis Rheum 37: 1583–1592

    Article  CAS  Google Scholar 

  18. Demitrack MA and Crofford LJ (1998) Evidence for and pathophysiologic implications of hypothalamic–pituitary–adrenal axis dysregulation in fibromyalgia and chronic fatigue syndrome. Ann NY Acad Sci 840: 684–697

    Article  CAS  Google Scholar 

  19. Qiao ZG et al. (1991) Electrodermal and microcirculatory activity in patients with fibromyalgia during baseline, acoustic stimulation and cold pressor tests. J Rheumatol 18: 1383–1389

    CAS  PubMed  Google Scholar 

  20. Adler GK et al. (1999) Reduced hypothalamic–pituitary and sympathoadrenal responses to hypoglycemia in women with fibromyalgia syndrome. Am J Med 106: 534–543

    Article  CAS  Google Scholar 

  21. Martinez-Lavin M et al. (1998) Circadian studies of autonomic nervous balance in patients with fibromyalgia: a heart rate variability analysis. Arthritis Rheum 41: 1966–1971

    Article  CAS  Google Scholar 

  22. McBeth J et al. (2005) Hypothalamic–pituitary–adrenal stress axis function and the relationship with chronic widespread pain and its antecedents. Arthritis Res Ther 7: R992–R1000

    Article  CAS  Google Scholar 

  23. Glass JM et al. (2004) The effect of brief exercise cessation on pain, fatigue, and mood symptom development in healthy, fit individuals. J Psychosom Res 57: 391–398

    Article  Google Scholar 

  24. Lautenbacher S et al. (1994) Multi-method assessment of experimental and clinical pain in patients with fibromyalgia. Pain 59: 45–53

    Article  CAS  Google Scholar 

  25. Gracely RH et al. (2002) Functional magnetic resonance imaging evidence of augmented pain processing in fibromyalgia. Arthritis Rheum 46: 1333–1343

    Article  Google Scholar 

  26. Price DD and Staud R (2005) Neurobiology of fibromyalgia syndrome. J Rheumatol Suppl 75: 22–28

    PubMed  Google Scholar 

  27. Russell IJ et al. (1994) Elevated cerebrospinal fluid levels of substance P in patients with the fibromyalgia syndrome. Arthritis Rheum 37: 1593–1601

    Article  CAS  Google Scholar 

  28. Sarchielli P et al. (2001) Levels of nerve growth factor in cerebrospinal fluid of chronic daily headache patients. Neurology 57: 132–134

    Article  CAS  Google Scholar 

  29. Alpar EK et al. (2002) Management of chronic pain in whiplash injury. J Bone Joint Surg Br 84: 807–811

    Article  Google Scholar 

  30. Suzuki R and Dickenson A (2005) Spinal and suparaspinal contributions to central sensitization in peripheral neuropathy. Neurosignals 14: 175–181

    Article  CAS  Google Scholar 

  31. Kosek E et al. (1996) Sensory dysfunction in fibromyalgia patients with implications for pathogenic mechanisms. Pain 68: 375–383

    Article  CAS  Google Scholar 

  32. Julien N et al. (2005) Widespread pain in fibromyalgia is related to a deficit of endogenous pain inhibition. Pain 114: 295–302

    Article  Google Scholar 

  33. Baraniuk JN et al. (2004) Cerebrospinal fluid levels of opioid peptides in fibromyalgia and chronic low back pain. BMC Musculoskelet Disord 5: 48

    Article  Google Scholar 

  34. Russell IJ et al. (1992) Cerebrospinal fluid biogenic amine metabolites in fibromyalgia/fibrositis syndrome and rheumatoid arthritis. Arthritis Rheum 35: 550–556

    Article  CAS  Google Scholar 

  35. Yunus MB et al. (1992) Plasma tryptophan and other amino acids in primary fibromyalgia: a controlled study. J Rheumatol 19: 90–94

    CAS  PubMed  Google Scholar 

  36. Hadler NM (1996) If you have to prove you are ill, you can't get well. The object lesson of fibromyalgia. Spine 21: 2397–2400

    Article  CAS  Google Scholar 

  37. Hawley DJ and Wolfe F (1991) Pain, disability, and pain/disability relationships in seven rheumatic disorders: a study of 1,522 patients. J Rheumatol 18: 1552–1557

    CAS  PubMed  Google Scholar 

  38. Callahan LF et al. (1989) Self-report questionnaires in five rheumatic diseases: comparisons of health status constructs and associations with formal education level. Arthritis Care Res 2: 122–131

    Article  CAS  Google Scholar 

  39. Turk DC et al. (1996) Pain, disability, and physical functioning in subgroups of patients with fibromyalgia. J Rheumatol 23: 1255–1262

    CAS  PubMed  Google Scholar 

  40. Giesecke T et al. (2003) Subgrouping of fibromyalgia patients on the basis of pressure-pain thresholds and psychological factors. Arthritis Rheum 48: 2916–2922

    Article  Google Scholar 

  41. Giesecke T et al. (2005) The relationship between depression, clinical pain, and experimental pain in a chronic pain cohort. Arthritis Rheum 52: 1577–1584

    Article  Google Scholar 

  42. Gracely RH et al. (2004) Pain catastrophizing and neural responses to pain among persons with fibromyalgia. Brain 127: 835–843

    Article  CAS  Google Scholar 

  43. Peters ML et al. (2000) Do fibromyalgia patients display hypervigilance for innocuous somatosensory stimuli? Application of a body scanning reaction time paradigm. Pain 86: 283–292

    Article  CAS  Google Scholar 

  44. Goldenberg DL et al. (2004) Management of fibromyalgia syndrome. JAMA 292: 2388–2395

    Article  CAS  Google Scholar 

  45. White KP et al. (2002) Does the label “fibromyalgia” alter health status, function, and health service utilization? A prospective, within-group comparison in a community cohort of adults with chronic widespread pain. Arthritis Rheum 47: 260–265

    Article  Google Scholar 

  46. Arnold LM et al. (2000) Antidepressant treatment of fibromyalgia. A meta-analysis and review. Psychosomatics 41: 104–113

    Article  CAS  Google Scholar 

  47. Capaci K and Hepguler S (2002) Comparison of the effects of amitriptyline and paroxetine in the treatment of fibromyalgia syndrome. Pain Clinic 14: 223–228

    Article  Google Scholar 

  48. Anderberg UM et al. (2000) Citalopram in patients with fibromyalgia—a randomized, double-blind, placebo-controlled study. European Journal of Pain 4: 27–35

    Article  CAS  Google Scholar 

  49. Norregaard J et al. (1995) A randomized controlled trial of citalopram in the treatment of fibromyalgia. Pain 61: 445–449

    Article  CAS  Google Scholar 

  50. Fishbain D (2000) Evidence-based data on pain relief with antidepressants. Ann Med 32: 305–316

    Article  CAS  Google Scholar 

  51. Adelman LC et al. (2000) Venlafaxine extended release (XR) for the prophylaxis of migraine and tension-type headache: a retrospective study in a clinical setting. Headache 40: 572–580

    Article  CAS  Google Scholar 

  52. Gendreau RM et al. (2005) Efficacy of milnacipran in patients with fibromyalgia. J Rheumatol 32: 1975–1985

    CAS  PubMed  Google Scholar 

  53. Arnold LM et al. (2004) A double-blind, multicenter trial comparing duloxetine with placebo in the treatment of fibromyalgia patients with or without major depressive disorder. Arthritis Rheum 50: 2974–2984

    Article  CAS  Google Scholar 

  54. Farber L et al. (2001) Short-term treatment of primary fibromyalgia with the 5-HT3-receptor antagonist tropisetron. Int J Clin Pharmacol Res 21: 1–13

    CAS  PubMed  Google Scholar 

  55. Wiffen P et al. (2000) Anticonvulsant drugs for acute and chronic pain. The Cochrane Database Of Systematic Reviews, Issue 3, Art. No CD001133

  56. Crofford LJ et al. (2005) Pregabalin for the treatment of fibromyalgia syndrome: results of a randomized, double-blind, placebo-controlled trial. Arthritis Rheum 52: 1264–1273

    Article  CAS  Google Scholar 

  57. Redillas C and Solomon S (2000) Prophylactic pharmacological treatment of chronic daily headache. Headache 40: 83–102

    Article  CAS  Google Scholar 

  58. Scharf MB et al. (2003) The effects of sodium oxybate on clinical symptoms and sleep patterns in patients with fibromyalgia. J Rheumatol 30: 1070–1074

    CAS  PubMed  Google Scholar 

  59. Bennett RM (2001) Pharmacological treatment of fibromyalgia. J Funct Syndr 1: 79–92

    Google Scholar 

  60. Holman AJ and Myers RR (2005) A randomized, double-blind, placebo-controlled trial of pramipexole, a dopamine agonist, in patients with fibromyalgia receiving concomitant medications. Arthritis Rheum 52: 2495–2505

    Article  CAS  Google Scholar 

  61. Russell IJ et al. (2002) Therapy with a central alpha 2-adrenergic agonist (tizanidine) decreases cerebrospinal fluid substance P, and may reduce serum hyaluronic acid as it improves the clinical symptoms of the fibromyalgia syndrome. Arthritis Rheum 46: S614

    Article  Google Scholar 

  62. Williams DA et al. (2000) Randomized controlled trial of CBT to improve functional status in fibromyalgia. Am College Rheumatol 43: S210

    Google Scholar 

  63. Harris RE et al. (2005) Treatment of fibromyalgia with formula acupuncture: investigation of needle placement, needle stimulation, and treatment frequency. J Altern Complement Med 11: 663–671

    Article  Google Scholar 

  64. Assefi NP et al. (2005) A randomized clinical trial of acupuncture compared with sham acupuncture in fibromyalgia. Ann Intern Med 143: 10–19

    Article  Google Scholar 

  65. Eisen S et al. (2005) Gulf War veterans' health: medical evaluation of a U.S. cohort. Ann Intern Med 142: 881–890

    Article  Google Scholar 

  66. Gray G et al. (2002) Self-reported symptoms and medical conditions among 11,868 Gulf War-era veterans: the Seabee Health Study. Am J Epidemiol 155: 1033–1044

    Article  Google Scholar 

  67. Aaron LA et al. (2000) Overlapping conditions among patients with chronic fatigue syndrome, fibromyalgia, and temporomandibular disorder. Arch Intern Med 160: 221–227

    Article  CAS  Google Scholar 

  68. Aaron LA and Buchwald D (2001) A review of the evidence for overlap among unexplained clinical conditions. Ann Intern Med 134: 868–881

    Article  CAS  Google Scholar 

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Author information

Authors and Affiliations

  1. Clinical Lecturer in Rheumatology at the University of Michigan, MI, USA

    Dina Dadabhoy & Daniel J Clauw

  2. Professor of Medicine, the Director of the Chronic Pain and Fatigue Research Center and the Center for the Advancement of Clinical Research, and the Assistant Dean for Clinical and Translational Research,

    Dina Dadabhoy & Daniel J Clauw

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  1. Dina Dadabhoy
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Correspondence to Dina Dadabhoy.

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Dadabhoy, D., Clauw, D. Therapy Insight: fibromyalgia—a different type of pain needing a different type of treatment. Nat Rev Rheumatol 2, 364–372 (2006). https://doi.org/10.1038/ncprheum0221

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