Fibromyalgia

Sonia Nagda

October 2012

What Is Fibromyalgia and How Do I Know If I Have It?

Fibromyalgia causes pain and suffering that is difficult to correctly diagnose or to fix.

Approximately 5 million people in the United States have fibromyalgia, a disease that affects muscles in every part of the body, causing deep aching pain, difficulty sleeping, and tiredness.[1]

How do you know if your muscle pain is fibromyalgia and not just everyday aches or related to an injury? In 2010, the American College of Rheumatology, which is a medical association for rheumatologists, created three criteria to diagnose fibromyalgia:[2]

1.      Muscle pain in several of 19 specific areas of the body over the past week, measured by the widespread pain index (WPI) and moderate to severe symptoms of fatigue, waking up feeling refreshed, and memory problems over the past week, measured by the symptom severity scale (SS).

2.      Similar symptoms and level of severity over at least three months.

3.      No other illness or injury that can explain the pain and other symptoms.

Fibromyalgia can be mistaken for other illnesses, such as myofascial pain syndrome, which consists of muscle pain in the head, neck, and torso; chronic fatigue syndrome; or hypothyroidism (low thyroid hormone).[2] Unlike fibromyalgia, which is sometimes accompanied by depression or anxiety, myofascial pain syndrome is not linked to changes in mood or mental health. Chronic fatigue syndrome also involves pain and tiredness, but the pain is caused by inflammation, which is not the case for fibromyalgia. Hypothyroidism can affect a person’s mind, mood, and body similar to fibromyalgia, but it usually includes other symptoms that are unique to having low thyroid hormones. A visit to a healthcare professional, with a physical examination and possible blood tests, can help you find out if you have fibromyalgia or another disorder.

What Causes Fibromyalgia and Who is at Risk?

No one really knows what causes fibromyalgia. The people most likely to have fibromyalgia have a family member with the disease, are middle-age or older, and female. In fact, seven women are diagnosed with fibromyalgia for every man with the disease.[1] In addition, people diagnosed with fibromyalgia often have a history of trauma, abuse, and sleep disorders.[2]

Stress caused by emotional pain, medical illness, surgery, or trauma can trigger fibromyalgia. Fibromyalgia is also more common in people with anxiety and depression. Does fibromyalgia cause anxiety and depression or are people who are anxious or suffering from depression more likely to develop fibromyalgia? We don’t know the answer. What we do know is that fibromyalgia patients are five times as likely to suffer from depression as people in the general public, and chronic stress and feelings of sadness can make the pain symptoms of fibromyalgia worse.[3] More than half of patients with fibromyalgia also suffer from migraine headaches.[2] These “comorbid disorders”-health problems that tend to go hand-in-hand with fibromyalgia-can greatly harm the quality of life for patients with fibromyalgia.[4]

Treating Fibromyalgia

Medications and other therapies targeted to treat the symptoms of pain and depression are used to treat fibromyalgia. Currently, the only drugs approved by the Food and Drug Administration (FDA) for the treatment of fibromyalgia are duloxetine (brand name Cymbalta, an antidepressant), pregabalin (brand name Lyrica, a neurological drug used to treat pain from damaged nerves), and milnacipran (brand name Savella, a drug that is similar to Cymbalta that has been approved by the FDA to treat fibromyalgia but not depression).[4] None of these medications are very effective.

When testing whether a medication works to reduce pain, the FDA requires that the patients report at least a 30% reduction in pain. Cymbalta was shown to have that level of pain reduction in 42% of patients, compared with 32% on placebo. Although statistically significant, that is not a major difference, and it shows how subjective pain is and how effective a placebo can be.  Moreover, many patients stopped taking this medication because of the side effects, which can include difficulty sleeping and reduced libido (interest in engaging in sexual activity).[5]

Analysis of clinical trials using different doses of Lyrica showed that it worked for only 9% to 14% of fibromyalgia patients, and approximately the same percentage stopped taking Lyrica because of the side effects.[6]

While Savella is the only drug approved by the FDA specifically for fibromyalgia and not any other illnesses, it does not work well long-term, which is a major shortcoming because fibromyalgia is a life-long disease. Also, there are many serious side effects that only became known after the drug was approved: suicidal ideation (1.3% in patients on 200mg/day of Savella compared to 0.5% of patients on placebo), high blood pressure (20% of people taking the 100mg/day of Savella went from having normal blood pressure to high blood pressure in one study, compared to 7% in people taking placebo), liver damage (6% and 7% in patients on 100mg/day and 200mg/day of Savella, compared to 3% in placebo patients), male sexual dysfunction (ejaculation problems in 7% and erectile dysfunction in 6%, compared to 0% in placebo), and harm to the fetus in pregnant animals.[7] In summary, although worth trying, for many patients the side effects may be worse than any benefits.

Additional medications that are sometimes used to treat fibromyalgia patients include other antidepressants (such as amitriptyline/Elavil), muscle relaxants (such as cyclobenzaprine/Flexeril), and pain medications (such as tramadol/Ultram).[1],[2] Because the brain pathways that cause pain and depression are similar, many patients take antidepressants to get some relief from both symptoms.

Some small studies have shown that a drug used to treat opioid and alcohol addiction, naltrexone (ReVia) has been successful in easing the pain of fibromyalgia.[8],[9] In one study with only 10 patients, all of them showed improvement more than when taking a placebo, and side effects were uncommon. While your doctor can prescribe naltrexone “off label” (for a use not approved by the FDA), remember that when a drug is tested on only 10 fibromyalgia patients, there isn’t enough data to prove that it is safe or effective for most fibromyalgia patients. By taking it, you are essentially participating in an uncontrolled experiment.

There are safer treatments than drugs and most seem to be at least as likely to be effective.  Therapies that improve the symptoms of fibromyalgia include exercise that increases the heart rate, mental health therapy by a psychologist or psychiatrist, and education to learn more about the illness and how to manage the symptoms.[10] Acupuncture, which involves placing many very thin needles into various pressure points on the body, reduced pain in fibromyalgia patients in eight of nine studies.[11] The researchers concluded that acupuncture may need to be done once or twice weekly on a regular basis to get any benefit from the treatments, and even then, it only works in some people.  Spa bathing treatments using hot or cold water, also known as balneotherapy, may reduce pain, especially if healing minerals are added to the water. In six small studies with less than 50 patients each, four found that the pain was reduced after an electric current was used in the water (there is no risk of electric shock with balneotherapy).

Massage was more helpful in three of four studies when compared to relaxation, electrical stimulation (TENS), or no treatment.  Meditation using mindfulness reduced pain in one study and the Chinese qigong method of breathing exercises reduced pain in two of three studies.

If you have any of the signs and symptoms of fibromyalgia, see your healthcare provider to discuss them and get a physical exam. Although some doctors do not recognize fibromyalgia as a disease, a primary care doctor should still be able to refer you to a specialist, such as a rheumatologist, neurologist, psychiatrist, or pain specialist, who knows more about fibromyalgia and can better treat your condition. Fibromyalgia is a chronic illness, but some people have been able to reduce or control certain symptoms with appropriate treatments.

REFERENCES

[1]Wierwille L. “Fibromyalgia: Diagnosing and managing a complex syndrome.” Journal of the American Academy of Nurse Practitioners 2012; 24: 184-192.

[2]Wolfe F, Clauw DJ, Fitzcharles M-A, et.al. “The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity.” Arthritis Care and Research 2010; 62(5): 600-610.

[3]Homann D, Stefanello JMF, Goes SM, et.al. “Stress Perception and Depressive Symptoms: Functionality and Impact on the Quality of Life of Women with Fibromyalgia.” Revista Brasileira de Reumatologia 2012 Jun; 52(3): 324-330.

[4]Marcus DA. “Fibromyalgia: Diagnosis and Treatment Options.” Gender Medicine 2009; 6: 139-151.

[5]Hauser W, Wolfe F, Tolle T, et.al. “The role of antidepressants in the management of fibromyalgia syndrome: a systematic review and meta-analysis.” CNS Drugs 2012 April 1; 26(4):297-307.

[6]Smith MT, Moore BJ. “Pregabalin for the treatment of fibromyalgia.” Expert Opinion on Pharmacotherapy 2012; 13(10):1527-1533.

[7]Barbehenn E, Wolfe S. “Petition to Ban Fibromyalgia Drug Milnacipran (Savella).”Citizen.org. Public Citizen, 20 Jan. 2010. Web. 27 June 2012. .

[8]Younger J, Mackey S. “Fibromyalgia Symptoms Are Reduced by Low-Dose Naltrexone: A Pilot Study.” Pain Med 2009 May-Jun; 10(4): 663-672.

[9]Ramanathan S, Panksepp J, Johnson B. “Is Fibromyalgia An Endocrine/Endorphin Deficit Disorder? Is Low Dose Naltrexone a New Treatment Option?” Psychosomatics 2012 April 3. Web. At: http://www.psychosomaticsjournal.com/article/PIIS0033318211003562/abstract?rss=yes. Accessed 27 Jun 2012.

[10]Clauw DJ. “Fibromyalgia: An Overview.” The American Journal of Medicine 2009; 122: S3-S13.

[11]Porter NS, Jason LA. Boulton A, et.al. “Alternative Medical Interventions Used in the Treatment and Management of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome and Fibromyalgia.” The Journal of Alternative and Complementary Medicine 2010; 16(3): 235-249.