Fibromyalgia
Fibromyalgia is a chronic pain disorder characterized by
widespread musculoskeletal pain accompanied by a cluster of neurological, psychological, and physical symptoms.
It occurs more frequently in women (about 70–80% of cases) and is usually diagnosed between the ages of 30 and 50, although it can occur at any age.
1. Pathophysiology (Disease Mechanism)
Fibromyalgia is considered a disorder of
central pain processing (Central Sensitization),
meaning the central nervous system becomes overly sensitive to painful—and even non-painful—stimuli.
Key proposed mechanisms:
-
Increased pain neurotransmitters in the CNS, such as:
- Substance P
- Glutamate
-
Reduced pain‑inhibiting systems
Decreased levels of:
- Serotonin (5‑HT)
- Norepinephrine
-
Dysregulation of the Hypothalamic‑Pituitary‑Adrenal (HPA) axis
-
Disturbed deep sleep (N3 stage), which worsens pain and fatigue
-
Altered pain processing in brain regions
(shown in fMRI studies)
Important note:
In fibromyalgia, there is no structural damage to muscle or joints.
The problem lies in pain processing—the pain is genuinely felt by the person.
2. Clinical Symptoms
The main symptom:
Chronic widespread pain (for at least 3 months)
Pain characteristics:
- Both sides of the body
- Above and below the waist
- Involvement of axial skeleton
Common associated symptoms:
- Severe fatigue
- Sleep disturbance (non‑restorative sleep)
- Morning stiffness
- Fibro fog (cognitive dysfunction), including:
- Poor concentration
- Short‑term memory difficulties
Other symptoms:
- Headache or migraine
- Irritable Bowel Syndrome (IBS)
- Restless Legs Syndrome
- Anxiety and depression
- Dysmenorrhea
- Sensitivity to sound, light, and touch
3. Tender Points
In older criteria (ACR 1990),
having ≥11 out of 18 tender points was required.
Classical tender points include:
- Occiput (back of the head)
- Trapezius (shoulders)
- Supraspinatus (shoulder blade region)
- Lateral epicondyle (outer elbow)
- Gluteal region
- Greater trochanter (outer thigh)
- Knee
These criteria are used less commonly today.
4. New Diagnostic Criteria (ACR 2016)
Diagnosis is based on two scales:
1️⃣ Widespread Pain Index (WPI)
Number of painful body regions (0–19)
2️⃣ Symptom Severity Scale (SS)
Severity of:
- Fatigue
- Sleep disturbance
- Cognitive problems
- Other physical symptoms
Diagnosis is made if:
- WPI ≥ 7 and SS ≥ 5
or
- WPI 4–6 and SS ≥ 9
Plus:
- Symptoms present ≥ 3 months
- No other condition that better explains them
5. Differential Diagnosis
Very important, since there is no specific lab test.
Conditions to rule out:
- Hypothyroidism
- Polymyalgia rheumatica
- Rheumatoid arthritis
- SLE
- Myopathies
- Chronic fatigue syndrome
- Vitamin D deficiency
Lab tests are usually normal.
6. Treatment
Treatment should be multimodal.
A) Non‑pharmacological treatment (most important)
- Patient education
- Regular aerobic exercise:
- Walking
- Swimming
- Stationary cycling
- Cognitive Behavioral Therapy (CBT)
- Improving sleep hygiene
- Stress reduction
- Yoga or Tai Chi
Exercise is the most effective long‑term treatment.
B) Medications
First‑line medications:
- Duloxetine
- Milnacipran
- Pregabalin
Other helpful medications:
- Amitriptyline (low dose at night)
- Cyclobenzaprine
- Gabapentin
Medications not recommended:
- NSAIDs (limited benefit)
- Opioids (strongly discouraged)
7. Prognosis
Fibromyalgia is:
- Non‑inflammatory
- Non‑destructive
- Not life‑threatening
But it can significantly reduce quality of life.
With a combination of:
exercise + psychological therapy + medication
symptoms are usually manageable.
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