Fibromyalgia is a challenging medical condition with multiple core symptoms including multifocal pain, fatigue, insomnia, cognitive or memory problems, and psychological stress. Multiple disorders coexist with fibromyalgia including regional musculoskeletal pain syndromes, chronic fatigue syndrome, irritable bowel syndrome, irritable bladder syndrome or interstitial cystitis, headaches, vulvodynia, and pelvic pain. Pathophysiology of fibromyalgia is attributed to decreased descending analgesic activity and increased wind-up or temporal summation.
Diagnosis of fibromyalgia as defined by ACR requires widespread pain index (WPI) greater than or equal to 7 and symptom severity scale (SSS) score greater than or equal to 5 or WPI 4-6 and SSS score greater than 9, generalized pain of at least 4 out of 5 regions, duration of at least 3 months, no other diagnostic explanation for symptoms. Differential for fibromyalgia is hypothyroidism, polymyalgia rheumatica, autoimmune disorders (rheumatoid arthritis, SLE), Sjogren’s syndrome as well as less common disorders including hepatitis C, sleep apnea, Chiari malformation, celiac sprue.
Pharmacological treatments of fibromyalgia include tricyclic antidepressants (amitriptyline, nortriptyline), serotonin-norepinephrine reuptake inhibitors (duloxetine, venlafaxine), alpha 2 delta ligands (pregabalin, gabapentin). Non pharmacological treatments of fibromyalgia are also key to sustained remission including low intensity, low impact exercise programs, behavioral medicine programs including cognitive behavior therapy and psychological support. FDA approved drugs are pregabalin (lyrica), duloxetine (Cymbalta), and Milnacipran [SNRI] (Savella). Glutamate is increased in this patient population secondary to wind up.