What is fibromyalgia?
What are its symptoms?
Who gets FM?
How is it diagnosed?
What causes FM?
How is FM treated?
What is the prognosis?

What is Fibromyalgia?

Fibromyalgia (FM) is a common medical condition characterized by widespread pain and stiffness, fatigue, sleep problems and cognitive difficulties. The illness does not damage tissue and is not progressive or fatal. The severity of fibromyalgia varies greatly from patient to patient. Some people with FM continue to work, though a significant minority are disabled.

Fibromyalgia touches many parts of a person's life and affects the lives of those around her. People with FM struggle to control symptoms, and to adapt to the limitations and stresses brought by their illness. Also, they must deal with loss, uncertainty and often lack of understanding from others. Family members have to come to terms with loss as well and frequently take on new responsibilities. There are usually financial consequences; many patients stop working, reduce their hours or retire early.

What Are Its Symptoms?

Fibromyalgia is characterized by the presence of multiple symptoms. The severity of symptoms often waxes and wanes. The most common symptoms are pain, poor sleep, fatigue and cognitive problems.

Pain: Chronic widespread pain is the most common symptom of fibromyalgia. The pain, which is described as aching, burning or stabbing, is generally felt all over the body, though it can start in one region and spread or move from one area to another. It may be accompanied by neurological problems such as tingling and burning or numbness in the hands, arms, feet, legs or face. The pain may be intensified by overactivity, non-restorative sleep, anxiety and stress, and changes in the weather.

Poor Sleep: The second-most common symptom of FM is poor sleep. Patients may have trouble falling asleep or may wake up frequently. In most cases, sleep is not experienced as restorative or refreshing, probably because of the limited time spent in deep sleep. Most patients suffer from a sleep disorder, but poor sleep is also caused by other factors such as stress, overactivity, and the absence of a good sleep environment or good sleep habits.

Fatigue: About three-quarters of FM patients report fatigue of the type felt by people with CFS. Characterized by a deep sense of exhaustion, fatigue can manifest as listlessness, sleepiness and a reduced tolerance for exercise. Like pain, the fatigue of FM can be intensified by overactivity, poor sleep, emotions and stress.

Cognitive Problems: Many fibromyalgia patients experience cognitive difficulties, often called "fibro fog." These cognitive problems include confusion, fumbling for words, lapses in memory and difficulty concentrating. Fibro fog is often aggravated by excessive activity, non-restorative sleep, strong emotions, stress and too much sensory input.

Other Symptoms: Many other symptoms may accompany fibromyalgia, creating additional discomfort and frustration. Common additional symptoms include tension or migraine headaches, strong emotions such as depression and anxiety, jaw pain, ringing in the ears, dizziness, rashes, sensitivity to light, sounds, smells and temperature, and dry eyes or dry mouth.

Who Gets Fibromyalgia?

Like CFS, fibromyalgia is a common illness. Estimates vary, but there are probably at least four to five million people in the United States with fibromyalgia, possibly many more. Studies suggest that up to 90% are women.

How is it Diagnosed?

There is no diagnostic marker for the illness in a patient's blood or evidence of the illness that appears through X-rays or other testing. Given the absence of diagnostic tests, FM is identified from the patient's report of symptoms and a medical history and physical examination. Diagnosis is often a prolonged process. Studies suggest that it takes an average of five years after the first appearance of symptoms to get a diagnosis.

Since 1990, fibromyalgia has been diagnosed through the identification of a particular pattern of symptoms:

• A history of at least three months of pain in many parts of the body (left and right sides, above and below the waist)
• Pain in at least 11 of 18 specific "tender points" on the body. Tender points are locations on the body that are painful when pressed. Such points in fibromyalgia are found in particular locations around the neck, shoulders, chest, elbows, lower back, hips and knees. 

In 2010, American College of Rheumatology provisionally accepted alternative criteria for diagnosing FM. The new criteria assess pain differently and also include assessment of other symptoms.

In the new criteria, pain is rated using the widespread pain index (19 areas on the body). Also, symptom severity is rated on symptoms that include fatigue, unrefreshing sleep, cognitive problems and physical problems such as headaches, bowel issues, nausea, dizziness and numbness/tingling. A diagnosis of FM is made based on a combination of the pain index and symptom severity scores. (For a two-page form you can fill out to see if you have FM, search online for "Widespread Pain Index and Symptoms Severity Score.")

Fibromyalgia can develop on its own or in combination with one or more additional medical problems. More than half of fibromyalgia patients also experience Chronic Fatigue Syndrome. Some of the conditions frequently found in people with fibromyalgia include:

• Allergies and chemical sensitivities
• Arthritis
• Depression
• Gastroesophageal reflux disease (GERD)
• Headaches
• Irritable bladder syndrome (interstitial cystitis)
• Irritable bowel syndrome (IBS)
• Myofascial pain
• Orthostatic problems such as neurally mediated hypotension (NMH) and postural orthostatic achycardia syndrome (POTS)
• Sleep disorders such as apnea and restless legs syndrome
• Tempomandibular joint disorder (TMJ)
• Thyroid problems 
• Vulvodynia

The presence of other illnesses can intensify fibromyalgtia symptoms. Treating other conditions can reduce fibromyalgia symptoms.

What Causes FM?

The cause of fibromyalgia is still unknown but current research focuses on how pain signals are amplified by the central nervous system (brain and spinal cord). This theory of often called the "central sensitization" model, a conrast to the idea of pain as a signal sent to the brain in response to an event in the body. Fibromyalgia patients have elevated levels of substance P and other neurotransmitters that express pain signals, and lower levels of chemicals such as serotonin, norepinephrine, and dopamine that mute pain sensations.

There is evidence suggesting a genetic susceptibility to fibromyalgia. The onset of FM is often triggered by an illness or trauma such as a fall or accident. It is possible that there are multiple causes for fibromyalgia, each of which produce increased pain.

How is Fibromyalgia Treated?

Like treatment of CFS, treatment of fibromyalgia focuses on controlling symptoms rather than cure. Approaches include medications, alternative treatments and self-help measures.

Medications are often used for improving sleep and controlling pain, though their effectiveness varies greatly from patient to patient. Medication regimens are usually developed through experimentation with different medications and dosages. Exercise is commonly recommended, both for reducing pain and stiffness, and for reversing deconditioning. The lifestyle adjustment strategies used with CFS, such as pacing and stress management, are also appropriate for fibromyalgia patients.

The three principles that govern treatment of CFS apply also to fibromyalgia:

1. The use of multiple strategies
2. Experimentation
3. An emphasis on lifestyle change.

Because fibromyalgia patients usually have more than one symptom and because each symptom usually has more than one cause, it is helpful to use a combination of treatments and coping strategies. Since there is no standard treatment for fibromyalgia and treatments helpful during one period may later become ineffective, patients have to experiment to find what works for them. Lifestyle adjustments, which are inexpensive and safe, typically produce more predictable results.

Pain 

Just as with CFS, pacing is an effective strategy for controlling pain in FM. Staying within activity limits, having short activity periods, switching tasks frequently and taking rest breaks are all helpful. Because pain is felt more intensely when a person is tired or under stress, reducing fatigue and stress also reduces pain.

Similarly, poor sleep intensifies pain, so improving sleep is also a way to control pain. Other common pain control strategies include heat and cold treatments, massage, attention to body mechanics (how the body is held and how it moves), and relaxation and other stress reduction measures.

Pain relief is often sought through medications:

• Non-prescription products such as aspirin and other over-the-counter pain relievers
• Prescription medications intended primarily for sleep
• Anti-depressants such as Elavil (Amitriptyline), Prozac and Paxil
• Anti-epileptic drugs
• Prescription pain relievers such as Ultram (tramadol).

Further, exercise is often used to reduce stiffness and to streangthen muscles.  In 2007, the FDA approved Lyrica (pregabalin) as the first drug tested and proved helpful for the treatment of fibromyalgia. Since then, two other drugs have been approved: Cymbalta (duloxetine hydrochloride) and Savella (milnacipran HCl). 

Sleep 

Treating sleep is another area in which use of an experimental approach involving a variety of strategies is helpful. No single medication has proven helpful in treating sleep problems for all FM patients. Also, drugs that are effective for a while may later become ineffective.

Medications commonly used to treat sleep problems include over the counter products like melatonin and valerian, antihistamines such as Benadryl (diphenhydramine), clonazepam (Klonopin), trazodone, or tricyclic antidepressants such as amitriptyline, benzodiazepines such as Halcion and the hypnotic drug Ambien. Non-benzodiazepine sleep medications such as Lunesta (eszopiclone), Sonata (zaleplon), and Rozerem (ramelteon) are also very effective and thought to be less habituating. Often, a combination of two drugs is prescribed, one to initiate sleep and another to maintain sleep.

Sleep can be improved through using good sleep habits such as having regular times to go to bed and get up, limiting daytime napping, not watching TV or using the computer during a wind down time before going to bed, avoiding caffeine and other stimulants for several hours before bedtime, and practicing relaxation (taking a bath or meditating) to fall asleep. Good sleep is also promoted by having a quiet environment, a good bed and an appropriate temperature in the bedroom. Reducing pain before going to bed and letting go of worries with techniques such as a worry log or To Do list for the next day can also help improve sleep.
 

Sleep disorders such as sleep apnea and restless legs syndrome are very common in people with CFS and sleep can be improved by treating them.

Fatigue 

Fatigue is usually addressed using lifestyle change, especially pacing. Pacing or living within limits includes strategies such as setting priorities, taking regular rests, having short activity periods, living by a schedule, and managing special events like vacations and holidays.

Fatigue can also be lessened by addressing pain and poor sleep, both of which intensify fatigue. Stress management, exercise and healthy eating can help reduce fatigue by addressing other causes of fatigue: stress, deconditioning and poor nutrition.

Cognitive Problems 

Strategies that are generally helpful for reducing the symptoms of fibromyalgia, such as pacing and stress management, also help reduce brain fog. Other techniques that often produce some control of fog include getting good sleep, doing one thing at a time (avoiding multi-tasking), limiting sensory input, using lists and other reminders, having daily and weekly routines, and keeping an orderly physical environment.

For more on treatment options for these symptoms of fibromyalgia, see the Treating Symptoms section of the site.

Stress, Emotions, Support & Loss 

As mentioned earlier, fibromyalgia has comprehensive effects, touching many parts of patients' lives and creating challenges beyond dealing with symptoms. A treatment plan should address, in addition to symptom management, issues such as managing stress and emotions, strengthening support systems and coming to terms with loss. Dealing successfully with these additional challenges usually reduces symptoms, so is also a form of symptom management.

For more on stress, emotions,  and support, see the Stress & Emotions and Relationships sections of the site.

What is the Prognosis?

Just as there is no cure for CFS, there is no treatment that cures fibromyalgia. Some people with FM improve, but total recovery is unlikely and some people experience prolonged relapses. A 1997 multi-center study of FM found 4% to 25% of patients are disabled, and the majority are unable to work most days. A 2011 10-year longitudinal study found a slight trend toward improvement in symptom severity overall, and 25% had at least moderate improvement of pain over time.

As with CFS, the course of fibromyalgia may vary. The location and severity of pain can change over time. Symptoms can be intermittent, fluctuating or persistent. Triggers of symptom intensification may include excessive activity, inactivity (deconditioning), stress, trauma, repetitive motion, poor sleep, strong emotions and weather changes.

The program on this site is based on the belief that most patients can find things to help them feel better. These strategies are not aimed at curing fibromyalgia, but they can help reduce pain and discomfort, bring greater stability and lessen suffering. Improvement requires effort, courage, discipline and patience. In the words of Dr. Lapp, the key to improvement is “acceptance of the illness and adaptation to it by means of lifestyle changes, for which medical treatment is no substitute.”