On this page, BHC breaks down the diagnostic criteria for fibromyalgia (FM) and provides videos, handouts, and health management guidance.
What is FM?
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 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. 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.
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.
- FIQR (Fibromyalgia Impact Questionnaire-Revised) FIQR
- FM 2016 Diagnostic Criteria [PDF]
- Pain Diagrams
- Visual Analog Scales (VAS)
- MFI (Multidimensional Fatigue Inventory)
- RAND 36- Item Health Survey Sub-Scale Scores (SF-36)
- 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 health)
- 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.
- Watch out for ‘Fibro Flares’ caused by overdoing or pushing past your body’s limits.
Educational Resources & Evidence-based Literature
Educational Resources on FM
- Helpful Hints for Treating FM
- University of Michigan’s Chronic Pain and Fatigue Research Center:
- Low Dose Naltrexone (LDN) articles
- UUH lecture series on Chronic Fatigue and Widespread Pain (below):
Diagnostic Criteria over the Years
1990 American College of Rheumatology (ACR) Fibromyalgia Criteria.
Required only chronic widespread pain and tenderness (>11/18 TP).
- 1990 American College of Rheumatology (ACR) Fibromyalgia Criteria.
Wolfe F1, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, Tugwell P, Campbell SM, Abeles M, Clark P, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990 Feb;33(2):160-72.
- Fibromyalgia diagnosis: a comparison of clinical, survey, and ACR criteria https://www.ncbi.nlm.nih.gov/pubmed/16385512
Katz RS, Wolfe F, Michaud K. Fibromyalgia diagnosis: a comparison of clinical, survey, and American College of Rheumatology criteria. Arthritis Rheum. 2006 Jan;54(1):169-76
2010 ACR Fibromyalgia Criteria
Tender points were abandoned, pain is scored along with pain, sleep, fatigue and cognitive complaints.
- The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity.
Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, Russell AS, Russell IJ, Winfield JB, Yunus MB. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). 2010 May;62(5):600-10. doi: 10.1002/acr.20140. PMID: 20461783
- Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia.
Wolfe F1, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RS, Mease P, Russell AS, Russell IJ, Winfield JB.
Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J Rheumatol. 2011 Jun;38(6):1113-22. doi: 10.3899/jrheum.100594. Epub 2011 Feb 1.
2016 ACR Fibromyalgia Criteria
Revisions to the 2010/2011 fibromyalgia diagnostic criteria.
- 2016 ACR Fibromyalgia Criteria: Revisions to the 2010/2011 fibromyalgia diagnostic criteria.
Wolfe F1, Clauw DJ2, Fitzcharles MA3, Goldenberg DL4, Häuser W5, Katz RL6, Mease PJ7, Russell AS8, Russell IJ9, Walitt B10. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum. 2016 Dec;46(3):319-329. doi: 10.1016/j.semarthrit.2016.08.012. Epub 2016 Aug 30.