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Fibromyalgia

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Overview

Fibromyalgia is a disorder characterised by widespread pain with tender points at specific sites of unknown aetiology:

Epidemiology

  • Women are 10 times more commonly affected than men
  • Usually seen at 20-60 years of age, but all people can be affected
  • It is more common in people with rheumatic disease

Risk Factors & Associations

  • Family history of fibromyalgia
  • History of other rheumatological conditions
  • Age between 20-60 years
  • Female sex

Presentation

  • Chronic, widespread body pain
  • Diffuse tenderness to palpation on physical examination without evidence of systemic disease
  • Fatigue unrelieved by rest
  • Sleep disturbances
  • Mood disturbances
  • Cognitive dysfunction
  • Headaches
  • Numbness/tingling sensations
  • Stiffness
  • Sensitivity to sensory stimuli such as bright lights, strong odours, or noises

Signs on Examination

  • Examination is normal except for diffuse tenderness

Differential Diagnoses

Rheumatoid arthritis (RA)

  • RA usually has active signs of synovitis on examination
  • RA usually has RF or anti-CCP antibodies
  • In RA, ESR/CRP is usually elevated

Osteoarthritis (OA)

  • OA has joint swelling and inflammation
  • OA has x-ray changes

Vitamin D deficiency

  • Serum 25-hydroxyvitamin D is low

Chronic fatigue syndrome

  • There is considerable overlap and it is difficult to tell them apart

Polymyalgia rheumatica

  • Patients are typically older
  • There is associated hip and shoulder girdle pain but also significant weakness and stiffness
  • PMR responds extremely well to corticosteroids but fibromyalgia does not
  • ESR/CRP is raised

Hypothyroidism

Polymyositis/dermatomyositis

  • Weakness and muscle fatigue are present
  • Creatine kinase is elevated

Iron deficiency anaemia

Investigations

Fibromyalgia is a clinical diagnosis.

  • Other investigations should be considered to rule out other reasons for the patient’s symptoms:
    • FBC, rheumatoid factor (RF), ESR, TFTs, anti-CCP antibody, antinuclear antibody, vitamin D levels

Diagnosis

Diagnosis is clinical and can be made using the American College of Rheumatology (ACR) criteria.

Management

  • 1st line: pharmacotherapy + aerobic exercise + cognitive behavioural therapy
    • Amitriptyline, duloxetine, pregabalin or gabapentin
  • Analgesics naproxen or tramadol

Patient Advice

  • Patients should be educated on fibromyalgia and how it can be managed but not cured
  • Patients should be encouraged to exercise
  • Patients should have advice on sleep hygiene

Prognosis

  • The prognosis of fibromyalgia is difficult to predict

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