There is no known cure for FM, and treatments are most often focused on relieving pain and on improving sleep and physical and emotional functioning. The lack of identification of a specific mechanism for FM has resulted in a wide array of interventions. Those with the greatest efficacy are briefly reviewed below.
Oral medications are often prescribed for patients with FM, but the effectiveness of any specific agent is not uniform. Various trials have investigated the efficacy of many pharmacological preparations. Table 2 outlines drug classes that have been evaluated as potential treatments for FM.
Although many studies indicate that treatments provide statistically significant effects, absolute improvements in the most recently investigated drugs were often modest, averaging about 34%. For example, a significant clinical response for antidepressant medication showed a 25% to 37% reduction in symptoms, and overall efficacy was modest.38,39 Moreover, the clinical trials included in the meta-analyses of antidepressants were mostly of short duration (6 to 12 weeks). The longest study of tricyclic medications followed 208 patients treated with amitriptyline(Drug information on amitriptyline), cyclobenzaprine, or placebo for 6 months. Initial improvements were not sustained at 26 weeks.40
Medication that targets key symptoms (fatigue, sleep, and depression) should be considered as a component of FM treatment.2,41,42 Table 3 provides information about medications studied in randomized controlled trials with data about benefit, mode of action, dosage, and adverse effects. Providing symptomatic relief may enable patients to sleep better and to engage in physical activities. In particular, antidepressant medication may work because it not only addresses depression itself but may also help improve sleep quality or reduce pain severity, even at dosages lower than those used for clinical depression.
Low-dose tricyclic antidepressants (TCAs) and selective serotonin-norepinephrine reuptake inhibitors (SNRIs) can be effective in reducing pain in FM. The SSRIs have a less consistent positive outcome. TCAs and SNRIs may reduce pain independent of their antidepressant actions as a result of their serotonin- and norepinephrine(Drug information on norepinephrine)-mediated effects on the descending pain-inhibitory pathways in the brain and spinal cord.
Recently, the antiepileptic drug pregabalin(Drug information on pregabalin) that acts by disrupting neuronal signaling by binding to the alpha-2-delta subunit of voltage-gated calcium channels in the CNS has been approved by the FDA for the treatment of FM. Pregabalin, which has anxiolytic, sedative, and pain-alleviating properties, has also been approved by the FDA for the treatment of generalized anxiety disorders. Sleep problems are extremely prevalent in FM patients. One strategy that has been effective in FM is the combination of an antidepressant and an antiepileptic medication, such as gabapentin(Drug information on gabapentin) or pregabalin, although this has not been studied in randomized controlled trials.
In addition to pharmacological agents, treatments include a diverse array of modalities. Table 4 presents some of the most recent approaches.43,44
Heat and cold, massage, stretching, and a range of motion exercises can be helpful. Systematic reviews and meta-analyses have supported the benefits of exercise and spa therapies.45,46 Supervised exercise programs (eg, aerobic conditioning, muscle strengthening, flexibility training) may be helpful as long as care is taken not to overfatigue patients.