Fibromyalgia is a complex syndrome of widespread musculoskeletal pain and fatigue. The fatigue which promotes a heightened perception of pain is caused by disrupted, non-restorative sleep patterns. This heightened pain perception resolves with restoration of normal sleep. FM is also frequently associated with mood disturbances. Unfortunately many patients visit multiple doctors feeling frustrated and ignored.
FM is the most common cause of widespread pain in women between the ages of 18 and 60. FM is significantly less common in males.
Initially, patients tend to report their pain is "everywhere". Successful treatment depends on treating the 2-3 most problematic locations . Discomfort in the shoulders, upper and lower back and lateral upper thighs by the hips is common.
Fatigue, often severe, is universal. The fatigue is due to non-restorative sleep in FM. Nearly all patients report either difficulty falling asleep or frequent arousals with difficulty returning to sleep. Difficulty with sleep quantity, sleep quality, or both can occur. Sleep quality problems (nocturnal limb movement and snoring) are under-appreciated causes of FM.
Essentially, the cause of FM is non-restorative sleep, and treatment must focus on identifying the cause of sleep disruption. Normal sleep occurs when up to six cycles of sleep are completed, each of which has three to four stages. Stage four is most important and when one wakes up in stage two or three, the cycle must start over and return to stage one (light sleep).
One should initiate sleep within 20 minutes of turning out the light. If not, it is necessary to determine if the problem is due to difficulty relaxing from the life's stresses or due to a focal pain, commonly in the shoulder, back, neck, or hip region.
It is important to identify what causes a FM patient to reawaken many times during the night and what prevents an efficient return to sleep. Is it a shoulder, back, or knee pain, or a bladder problem requiring many trips to the bathroom? In this re-awakened state, many people with FM start "replaying" the stresses of their day. It may then take an hour or more to reinitiate sleep.
If a FM patient reports "no problem" with sleeping through the night, they likely have a problem with snoring or nocturnal limb movement (sleep quality).
Treatment begins with identifying the cause of sleep disruption. For back, shoulder, or hip and neck pain, one may need to stop lifting heavy items, have physical therapy, or get a local cortisone injection. A long-acting form of Tylenol (acetaminophen) or NSAID, such as Aleve (naproxen), before bedtime might be recommended.
Flexeril (cyclobenzaprine), a non-habit-forming muscle relaxant, or amitriptyline can be very helpful when taken before bedtime. Most people will not develop excessive sedation.
If stress, anxiety and fatigue persist after trying cyclobenzaprine and amitriptyline, a medication designed to correct a chemical deficiency in serotonin or nor-epinephrine often helps.
The SSRI family of medications (Prozac, Celexa, Zoloft, etc.), which elevate serotonin levels, and many of which are available as generic, are effective whether or not depression is diagnosed. Dual re-uptake inhibitors for serotonin and norepinephrine can be effective. Cymbalta and Savella are heavily advertised and expensive, but not necessarily more effective than the generic SSRI's.
Lyrica (pregabalin) is promoted for fibromyalgia. It is expensive, causes sedation, and should only be used at night when less expensive medications have not helped to restore restful sleep.
Unfortunately many patients are misdiagnosed with FM or too quickly prescribed these expensive medications. A thorough history and careful physical examination will often identify other, more easily treated musculoskeletal conditions, such as arthritis bursitis and myofascial pain.
With a comprehensive, persistent, patient-oriented approach including a graduated aerobic exercise regimen, nearly all fibromyalgia patients will have a good outcome.