An Overview of Fibromyalgia

Fibromyalgia is a chronic disorder characterized by widespread pain that is often accompanied by fatigue, depression, sleep disturbance, cognitive impairment, and digestive and urinary symptoms.

It is a poorly understood disorder in which pain signals processed by the brain appear to be exaggerated, amplifying the sensation of pain in muscles and soft tissues. There are no tests to identify it, so fibromyalgia is diagnosed by excluding other possible causes.

Treatment may involve over-the-counter pain relievers, antidepressants, physical therapy, self-care, and medications specifically approved to treat fibromyalgia, such as Lyrica (pregabalin). 

What does fibromyalgia feel like? It's about more than just muscle aches and joint pain. It is persistent, widespread pain that can move through the body in waves, causing sensations described as throbbing, diffuse, intense, or stabbing. Even mild changes in temperature or pressure (including touch) may trigger discomfort.

While some people maintain fairly consistent levels of symptoms, others will go through periods of remission alternating with periods of activity (flares). Beyond pain, fibromyalgia is associated with an almost dizzying array of symptoms affecting multiple organ systems. They include:

• Fatigue, usually chronic, affecting four out of five people with the disorder
• Muscle and joint symptoms such as muscle spasms, muscle weakness, and jaw pain
• Cognitive symptoms such as the loss of concentration, disorientation, and "brain fog"
• Sleep disorders such as broken sleep, sleep starts, and insomnia
• Neurosensory symptoms such as vertigo, migraine, or sensitivity to light, sound, or smells
• Gastrointestinal symptoms such as diarrhea, constipation, bloating, or cramping
• Urinary symptoms including bladder pain, pain during urination, or the frequent urge to urinate
• Psychiatric symptoms such as depression, mood swings, hypervigilance, or panic attacks
• Reproductive symptoms such as painful periods, pelvic pain, or early menopause

Temporary hair loss, heart palpitations, and the benign overgrowth of fatty tissue (lipomas) may also occur.

No one really knows what causes fibromyalgia. It is clustered with similar disorders, such as chronic fatigue syndrome (CFS) and irritable bowel syndrome (IBS), which are believed to be caused by an excessive response of the central nervous system to otherwise normal stimuli. 

People with fibromyalgia tend to unusually high concentrations of two chemicals, known as substance P and glutamate, in their body. Substance P and glutamate are involved in the transmission and regulation of pain information. By having such elevated levels of substance P and glutamate, the pain messages to and from the brain may effectively be over-exaggerated.

Similarly, a number of smaller studies have shown that people with fibromyalgia tend to have decreased blood flow to the thalamus, the section of the brain that acts as the center of pain perception. It is strongly believed that this may also contribute to the heightened pain perception.

At this stage, we simply don't know. What we do know is that certain risk factors may increase the odds of getting fibromyalgia. Among them:

• Women are nine times more likely to have fibromyalgia than men. It has been suggested that decreases in estrogen during menstruation and around the time of menopause. 
• Age is also a factor. Despite being considered a disorder affecting post-menopausal women, fibromyalgia is most often diagnosed between the ages of 20 and 50, although symptoms usually develop several years prior. Children can also have fibromyalgia.
• Stress appears to precipitate fibromyalgia symptoms. When accompanied by sleep problems, the perception of pain is further heightened as is the risk of fatigue and depression.
• Genetics are also believed to be a factor. Research suggests that having a parent or sibling with fibromyalgia significantly increases your risk.

With no lab or imaging tests able to confirm the disorder, diagnosis of fibromyalgia requires first excluding other possible causes of your symptoms. It can be a painstaking process that should be overseen by a rheumatologist or, alternately, a neurologist or general practitioner experienced with fibromyalgia or other connective tissue issues.

The ACR criteria include two score-based evaluations:

• The first, called the widespread pain index (WPI), assigns one point for each of the 19 body parts in which you’ve experienced pain (for a maximum of 19 points).
• The second, called the symptom severity (SS) scale, assigns 0 to 3 points—0 meaning no symptoms, 3 meaning serious symptoms—to each of four characteristic symptoms of the disorder (for a maximum of 12 points).

While these are physicians' tools, knowing more about them can give you a sense of what your doctor will factor into his diagnosis decision making.

To be diagnosed with fibromyalgia, you need to satisfy the following three conditions:

1. You must have either a) WPI of 7 or more with an SS score of 5 or more, or b) a WPI of 3 to 6 and an SS score of 9 or more.
2. You must have had these symptoms for at least three months.
3. There must be no other medical explanation for your symptoms.

There is no single pill that can treat fibromyalgia or ensure the sustained remission of symptoms. A multi-faceted approach is needed, which may include over-the-counter (OTC) and prescription medications, physical therapy and counseling, lifestyle interventions, and complementary therapies.

Because no two cases of fibromyalgia are alike, treatment can vary from one person to the next.

Medications and Therapy

Medications are typically the backbone of therapy. The choice of drugs is largely dependent on the types and severity of your symptoms and how well you tolerate any side effects. Among them:

• OTC pain relievers like Tylenol (acetaminophen) and nonsteroidal anti-inflammatory drugs (NSAIDs) like Advil (ibuprofen) or Aleve (naproxen) may provide short-term relief of minor pain.
• Prescription pain relievers such as Celebrex (celecoxib) or Voltaren (diclofenac) are longer lasting.
• Antidepressants can ease pain and fatigue while elevating mood by raising serotonin levels. The antidepressants Cymbalta (duloxetine) and Savella (milnacipran) are approved to treat fibromyalgia.
• Anticonvulsants may also be effective in treating pain. They include Lyrica (pregabalin), which is approved for the treatment of fibromyalgia, and others like Neurontin (gabapentin), which may be prescribed off-label.

Sleep problems are typically treated with low-dose antidepressants, like Elavil (amitriptyline), rather than sleeping pills. Muscle relaxers, like Flexeril (cyclobenzaprine), can also do double-duty by alleviating muscle tension while helping a person sleep.

In addition to medications, your doctor may refer you to specialists who can help you overcome physical or emotional challenges, including physical therapists, occupational therapists, psychiatrists, or counselors.

Lifestyle Modifications and Complementary Treatments

Stress alleviation is among the primary facets of any fibromyalgia treatment plan. Relaxation techniques and mind-body therapies are obvious and helpful options. But eating better, exercising, and avoiding things like caffeine, alcohol, and smoking can also help elevate your mood. In particular, physical activity triggers the release of serotonin, dopamine, and endorphins, what many dub "feel-good" chemicals.

Complementary approaches to treatment include:

• Meditation, guided imagery, and deep breathing (pranayama) to alleviate stress
• Yoga and Tai Chi, which incorporate controlled movements and the release of tension
• Massage therapy, especially gentler forms like Shiatsu or aromatherapy massage
• Progressive muscle relaxation (PMR), which focuses the release of tension by body part
• Biofeedback, which can teach you how to control the stress response
• Medical marijuana, which can reduce pain, elevate mood, and help you sleep better
• 5-HTP (5-hydroxytryptophan), a naturally-occurring amino acid that can be taken as a supplement, which may help raise serotonin levels

Despite increased public awareness, fibromyalgia remains a mystery to many peoples, some of whom may doubt its existence or suggest that it’s "all in your head." It is not.

Don’t let other people’s misconceptions prevent you from seeking the care you need. Find support from friends and family, opening up about not only what you feel but how you feel. Join a local support group or contact the National Fibromyalgia & Chronic Pain Association to find one near you. Building a support system can provide you with the confidence and education to become an advocate for your own care.

If your doctor is unable to help or understand your concerns, find a rheumatologist in your area through the online locator offered by the American College of Rheumatology. Drug co-pay and patient assistance programs are also available to help defray the cost of treatment, if you are eligible.