Medical Grand Rounds

What you can do for your fibromyalgia patient

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Patients with fibromyalgia typically have pain “all over,” tender points, generalized weakness and fatigue, nonrestorative sleep, and a plethora of other symptoms. In contrast to inflammatory and autoimmune conditions, laboratory tests and physical examination findings are usually normal. American College of Rheumatology guidelines facilitate diagnosis. Management requires a multifaceted, long-term strategy that emphasizes improving function rather than reducing pain.


  • Fibromyalgia is a clinical diagnosis, and specialized testing beyond basic laboratory tests is not indicated.
  • Antinuclear antibody test results can be confusing, and the test should not be ordered unless a patient has objective features suggesting systemic lupus erythematosus.
  • Treatment should be tailored to comorbidities such as depression, anxiety, and sleep disturbance. Options include serotonin-norepinephrine reuptake inhibitors (eg, duloxetine), selective serotonin reuptake inhibitors, low-dose tricyclic antidepressants (eg, amitriptyline), and gabapentinoids (pregabalin or gabapentin). These drugs can be used singly or in combination.
  • Medications that do not work should be discontinued.
  • “Catastrophizing” by the patient is common in fibromyalgia and can be addressed by education, cognitive behavioral therapy, and anxiolytic or antidepressant drugs.
  • Sustained, lifelong exercise is the treatment strategy most associated with improvement.



Fibromyalgia may seem like a nebulous diagnosis, with its array of symptoms and pain refractory to medications. But fibromyalgia is a defined syndrome of neuronal dysregulation. It can be diagnosed from the history and physical examination and managed in a primary care setting.


A 43-year-old woman presents to her primary care physician with multiple complaints: pain in all joints and in her back and hips, swelling of her hands and feet, morning stiffness, chest pain and shortness of breath (not necessarily related to exertion), fatigue, generalized weakness, headaches, difficulty with memory and concentration, dry mouth and dry eyes, feeling weak and faint in the sun, cold intolerance with purple discoloration of her extremities, a self-described “butterfly” rash on the face, and hair that is thinning and falling out in clumps.

Because many of her symptoms could reflect an inflammatory process or an autoimmune disease, 1 her primary care physician orders multiple tests. Her C-reactive protein level, Westergren sedimentation rate, complete blood cell count, and comprehensive metabolic panel are normal. Urinalysis shows trace leukocyte esterase. Indirect immunofluorescence assay on human laryngeal tumor (HEp-2) cells is positive for antinuclear antibody (ANA), with a titer of 1:320 (reference range ≤ 1:40) and a nuclear dense fine-speckled pattern.

In view of the positive ANA test, the patient is informed that she may have systemic lupus erythematosus (SLE) and will be referred to a rheumatologist. In the days before her rheumatology appointment, she becomes extremely anxious. Obsessively researching SLE online, she becomes convinced that SLE is the correct diagnosis.

Rheumatology evaluation

The rheumatologist assesses the patient’s pain and reports the following:

Location and duration: Hands, wrists, elbows, shoulders, upper and lower back, sides of hips, knees, and feet; has been ongoing for 10 years, but worse in the past 3 months.

Character: The patient describes her pain as “like an ice pick being driven through my joints,” “sometimes unbearable,” and “like being hit by a truck.” She also reports numb, tingly, burning pain in her upper neck and back.

Variation with time, activity, and weather: Worse at night, causing her to wake and toss and turn all night; better with exertion, but after activity or exercise, she is exhausted for the rest of the day and sometimes for up to a week; worse with weather changes, especially during cold or humid weather.

Associated symptoms: Occasional perceived swelling of hands and feet, especially upon wakening in the morning, and 2 to 3 hours of stiffness in the morning that sometimes lasts all day.

Physical examination. Her findings are inconsistent with her symptoms.

The patient exhibits limited range of motion. When asked to bend forward, rotate her neck, or flex and extend her neck and back, she does so only slightly. However, passive range of motion is normal in all joints.

When her joints are examined, she anticipates pain and withdraws her hands. But when she is distracted, examination reveals no evidence of swollen joints or synovitis. She has tenderness in 12 of 18 tender points. Her peripheral pulses are good, strength is normal, and reflexes are brisk.


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