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

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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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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