Medical Edge Newspaper Column

Treating Fibromyalgia Often Requires A Multifaceted Approach

May 16, 2008
Dear Mayo Clinic:
In 1997, I was diagnosed with fibromyalgia. In the past few months, my health problems seemed to get worse. I saw a neurologist and also a rheumatologist for more tests. They prescribed pregabalin (Lyrica) and also amitriptyline. Can you give me some insight into treating this condition?

Answer:
It would be wonderful if medications alone could cure or significantly improve fibromyalgia, a chronic condition that's associated with fatigue and widespread pain in the muscles, ligaments and tendons. But optimal management of fibromyalgia symptoms requires a multifaceted approach. Medications often are part of an effective treatment plan, but they aren't the sole answer.

That said, your doctors made reasonable recommendations. Pregabalin, an anti-seizure medication, helps reduce pain for some people with fibromyalgia. In 2007 it was the first medication approved by the Food and Drug Administration to treat fibromyalgia. In one study, about half of the patients taking the highest dose of pregabalin reported a 30 percent improvement in symptoms. Antidepressant medications, such as amitriptyline, also help some patients with fibromyalgia, usually at doses much lower than needed to treat depression.

Given that your condition has recently worsened and you have consulted with specialists to rule out other contributing factors, I suggest you consider a more holistic approach to managing and reducing symptoms. Ask your doctor to help you with a treatment plan to address three areas: improving sleep, better managing stress or depression; and improving muscle function.

Improving sleep — Many people with fibromyalgia wake frequently at night or have difficulty sleeping. That means a short supply of deep, restorative sleep that relaxes the body and restores energy. There's a host of self-care options to improve sleep. They include skipping caffeine; learning and practicing relaxation techniques; taking a warm bath at bedtime and avoiding naps. If self-care measures aren't enough, talk with your doctor about medications to help sleep. I think it's likely that you are taking the amitriptyline in a small dose at night. This is often used to help sleep. If it is well tolerated, the dose could be increased. If the amitriptyline isn't working, or side effects such as dry mouth or weight gain are unacceptable, then switching to trazodone (Desyrel), another antidepressant, is an option. The goal is to have restorative sleep so that you feel refreshed in the morning. Most over-the-counter sleep aids aren't effective at improving restorative sleep.

Managing stress — Chronic pain is stressful in many ways, affecting jobs, relationships and the ability to enjoy life. And stress can become part of an ever-worsening pain cycle. Stress causes muscle tension that intensifies pain, leading to more stress. Stress and pain can also contribute to depression, which isn't unusual among people with fibromyalgia.

So, for many reasons, it's important to minimize stress. Take steps to manage your stress, which can range from saying "no" to extra commitments to setting realistic expectations about what you can and can't get done. And be honest with your care provider about any depression symptoms and seek treatment if needed.

Improve muscle function — If you have considerable pain, exercise probably isn't at the top of your to-do list. However, for long-term pain reduction, it's important to move and gradually work up to better strength and endurance.

For patients who have dealt with pain for many years, it often takes intensive rehabilitation to "reprogram" the brain into a new way of reacting to pain triggers. There are many ways for a treatment plan to be customized to your specific needs and concerns. If your symptoms interfere with day-to-day activities, I'd suggest seeking care at a comprehensive pain rehabilitation program. These multiple-week programs offer treatment and education that is designed to deal with the many aspects of pain management, often using a technique called cognitive behavioral therapy.

— Jeffrey Thompson, M.D., Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minn.