Musculoskeletal

Fibromyalgia

Fibromyalgia is a chronic primary pain condition characterised by widespread pain with fatigue, unrefreshing sleep and cognitive difficulty; it is diagnosed clinically while assessing mimics and coexisting disease, and managed with person-centred exercise, psychological approaches, symptom care and selective medicine review rather than routine analgesics.

In a nutshell

Fibromyalgia is chronic primary pain with widespread pain, fatigue, unrefreshing sleep, cognitive difficulty and functional impact. Diagnose clinically while checking mimics and coexisting disease; there is no confirmatory test and tender-point counting is not the diagnosis. NICE recommends person-centred supervised exercise, ACT or CBT for pain, possible acupuncture and selective antidepressant use, and says not to initiate opioids, gabapentinoids, NSAIDs or paracetamol for chronic primary pain. Reassess for ME/CFS when post-exertional malaise dominates.

Classic presentation

A person has widespread pain for more than 3 months with fatigue, unrefreshing sleep and brain fog, but no synovitis, focal neurological deficit or systemic red flags. Agree goals and a shared plan after limited targeted testing rather than repeated investigations.

Key points

Fibromyalgia is a type of chronic primary pain; the pain is real and can coexist with other disease.
The typical cluster is widespread pain, fatigue, unrefreshing sleep, cognitive difficulty and functional impact.
Make a positive clinical diagnosis while using history, examination and limited targeted tests to assess mimics and red flags.
NICE recommends a supervised group exercise programme for chronic primary pain, tailored to abilities and preferences, plus ACT or CBT for pain; acupuncture may be considered.
Consider an antidepressant for adults after benefits and harms are discussed; this does not require depression.
Do not initiate opioids, gabapentinoids, NSAIDs or paracetamol for chronic primary pain; review existing medicines safely rather than stopping abruptly.
Prominent post-exertional malaise should trigger assessment for ME/CFS and must not be managed with a fixed exercise-escalation programme.

First-line investigation

Person-centred history and examination for widespread chronic pain, associated symptoms, function and red flags, with limited targeted tests for mimics or coexisting disease.

Management

Check red flags and validate the pain

Examine for synovitis, focal neurological signs, systemic features, proximal girdle symptoms, objective weakness and post-exertional malaise; validate the pain and urgently investigate red flags.^1,2,5

Make a positive clinical assessment

Use a limited targeted screen for mimics and assess function, sleep, fatigue, cognition, mood, comorbidity, work and goals; avoid repeated broad testing when there is no new indication.^1,2,3

Use active and psychological approaches

Offer a supervised exercise programme tailored to preferences and ability, plus ACT or CBT for pain; consider acupuncture with a discussion of uncertain or short-term benefit.^1,2,4
Consider an antidepressant for adults after a full benefits-and-harms discussion, and do not initiate opioids, gabapentinoids, NSAIDs or paracetamol for chronic primary pain.^1,6

Review function, medicines and new symptoms

Review pain, sleep, mood, function, activity, medicine benefit and adverse effects against the person's goals; reduce or continue existing medicines safely through shared decision-making.^1,6
Reassess new or worsening symptoms, including inflammatory signs, focal neurology and post-exertional malaise suggesting another or coexisting condition.^1,5,2

Exam traps

Normal tests do not mean symptoms are imaginary, but fibromyalgia can coexist with abnormal tests or another disease.
Tender points are not a substitute for a holistic diagnosis and are not required as a fixed examination count.
Do not initiate opioids, gabapentinoids, NSAIDs or paracetamol for chronic primary pain; review existing treatment through shared decision-making.
Exercise for fibromyalgia is not the same as fixed graded exercise therapy for ME/CFS; screen for post-exertional malaise and individualise safely.
Raised inflammatory markers, synovitis, objective weakness, focal neurology or systemic features need another diagnostic pathway.
CBT or ACT supports pain management and function; it does not imply that the pain is caused by psychological weakness.
New or changing symptoms require reassessment rather than automatic attribution to fibromyalgia.

Illustrations

Fibromyalgia symptom and care domainsA patient-centred diagram linking widespread pain, fatigue, unrefreshing sleep, cognitive difficulty, mood, function and flare planning to exercise, psychological therapy, symptom review and shared decision-making. Include a warning to reassess post-exertional malaise or objective inflammatory signs.Mikael Häggström, Wikimedia Commons · Public domain

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.