On this page, BHC breaks down the diagnostic criteria for fibromyalgia (FM) and provides videos, handouts, and health management guidance.
What is fibromyalgia?
Fibromyalgia (FM) is a chronic, widespread pain amplification disorder involving both central and peripheral nervous system sensitization throughout the body.
Fibromyalgia is often thought to be a secondary complication (comorbid) of an additional underlying illness or injury that may have promoted these chronic changes in nervous system signaling in a person susceptible to developing the disorder.
There are many aspects of FM that resemble that of ME/CFS, with the core difference being FM patients do not experience post-exertional malaise or PEM which is pathognomic to ME/CFS. It is important to differentiate that which is PEM vs. a flare, as flares can be misrepresented PEM. For more on PEM, see the Project ECHO seris on post-viral syndromes.
Fibromyalgia is often accompanied by its own secondary complications including migraines, irritable bowel syndrome, and interstitial cystitis.
Widespread pain, or hyperalgesia, may be described by patients in the following ways:
- Sharp shooting pain
- Tingling and numbness
- Light and sound sensitivity
- Pain which originates in the muscles, joints, bowel, bladder, pelvis, chest, head
What causes FM?
The causes of FM remain unclear and may differ from patient to patient. Research suggests involvement of the nervous system, particularly the central nervous system (brain and spinal cord). Fibromyalgia may run in families, and although there is likely a genetic component to the illness, genes alone do not cause FM. There likely are certain genes that can make people more prone to getting fibromyalgia and other comorbid conditions associated with it.
There are often ‘triggering factors’ which sets off FM. Injury, spinal conditions, physical stress, underlying rheumatic conditions, etc. The result is a change in the way the body “talks” with the spinal cord and brain. Levels of brain chemicals and proteins may change. More recently, fibromyalgia has been described as Central Pain Amplification disorder, meaning the volume of pain sensation in the brain is turned up too high.[Sources: Bateman Horne Center & American College of Rheumatology]
Symptoms include a lower pain threshold —although not necessarily a lower pain tolerance— and an amplified pain response that causes not only musculoskeletal pain, but may also contribute to headaches, tingling, chest and bowel or bladder pain. Fatigue, sleep dysregulation, and cognitive impairment/brain fog- termed “Fibro Fog” are also reported.
Common manifestations of sensory amplification disorders (FM):
- Muscle and joint pain and tenderness
- Migraine and tension headaches, TMJ/TMD
- Paresthesia (numbness and tingling)
- Restless legs syndrome
- Irritable bowel syndrome, IBS-D, IBS-C
- Irritable bladder, interstitial cystitis, painful menstruation, pelvic pain, vulvodynia
- Sensory (light, noise, olfactory, chemical, etc) sensitivities
Sicca syndrome (dry eyes and mouth)
- Heart palpitations, sinus tachycardia, low HRV
Research shows nonspecific changes in autonomic nervous system function, dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, and elevation of Substance P, glutamate and other pain neurotransmitters in the cerebrospinal fluid.
Functional MRI scans demonstrate more areas of pain processing in the brain for a given stimulus compared to normal people.
Sleep studies show profound alterations of brain waves during the stages of sleep.
Symptoms can become chronic and very difficult to treat, even after the “stress” is relieved and mood symptoms are well compensated. Poor coping skills or maladaptive behaviors, often related to lack of disease recognition and education, may compound FM symptoms and worsen prognosis.
Making a Diagnosis
2016 revisions to the 2010 FM diagnostic criteria indicate:
An adult meets criteria for being diagnosed with fibromyalgia when all of the following criteria are met:
- Generalized pain, defined as pain in at least 4 of 5 regions, is present.
- Symptoms have been present at a similar level for at least 3 months.
- Widespread pain index (WPI) ≥ 7 and symptom severity scale (SSS) score ≥ 5 OR WPI of 4–6 and SSS score ≥ 9.
- A diagnosis of fibromyalgia is valid irrespective of other diagnoses. A diagnosis of fibromyalgia does not exclude the presence of other clinically important illnesses.
- MFI (Multidimensional Fatigue Inventory)
- RAND 36- Item Health Survey Sub-Scale Scores (SF-36)
Managing FM often requires a multifaceted approach, which includes the “four table legs” of wellness. Finding a healthy balance between fitness and mental health, while addressing pain and sleep distrubances can greatly improve patient functioning and general well-being.
Address all chronic or comorbid medical conditions. Dig deeper into any unresponsive or atypical symptoms.
Prioritize and treat the major illness symptoms but economize medications.
- Incorporate positive behavioral change.
- Use medications that work for more than one aspect of FM (more than one leg of the table).
- Use the lowest effective doses (start low and go slow).
- Avoid causing new symptoms or side effects.
It’s also important to understand and manage the “4 table legs of wellness”
- Use medications effective for the type of pain experienced.
- FDA approved for FM: pregabalin, duloxetine, milnacipran.
- Non-FDA approved for FM: gabapentin, amitriptyline, cyclobenzaprine, tramadol, low-dose naltrexone (LDN).
- Non-FM pain may need to be considered and addressed separately (i.e. osteoarthritis).
- Practice good sleep hygiene.
- Diagnose and treat sleep disorders.
- Utilize appropriate medications, and watch for lingering side effects the following day, as this can lead to more symptoms of “brain fog.”
Psychological State (mental wellness)
- Help patient strike a balance between their personal and professional demands.
- Encourage your patient to practice good self-care and mindfulness.
Restorative exercise: strength, flexibility, low impact aerobic.
Be mindful of other comorbid conditions as they impact conditioning and pacing (such as ME/CFS) Assess for post-exertional malaise (PEM).
Watch out for ‘Fibro Flares’ caused by overdoing or pushing past your body’s limits. Fibro flares may actually be PEM, rule out ME/CFS.