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Fibromyalgia

• Signs and Symptoms
• What Causes It?
• What to Expect at Your Provider's Office
• Treatment Options
• Following Up
• Supporting Research

Fibromyalgia is a chronic condition characterized by pain in the muscles, ligaments, and tendons; fatigue; and multiple tender points on the body. While no one knows what causes it, there is evidence that people with fibromyalgia may be more sensitive to pain because something is wrong with the body's usual pain perception processes. More women than men have fibromyalgia. Fibromyalgia, while different for everyone who has it, tends to come and go throughout life. Although it can be debilitating for some people, it is not degenerative or life-threatening, and you can manage your symptoms and improve your quality of life with professional and self care.

Signs and Symptoms

• Widespread pain and stiffness
• Fatigue or trouble sleeping
• Paresthesia (tingling)
• Irritable bowel syndrome
• Skin sensitivity
• Heightened sensitivity to noises, bright lights, smells
• Depression
• Headaches
• Pain after exertion
• Memory lapses or difficulty concentrating
• Restless leg syndrome
• Dizziness
• Anxiety

It is not uncommon for people with fibromyalgia to have other conditions, including restless legs syndrome, irritable bowel syndrome, temporomandibular joint disorder (TMJ), and bladder problems.

What Causes It?

No one knows what causes fibromyalgia, although there are several theories, and multiple factors may bring on the condition.

• Changes in brain chemicals -- Some people with fibromyalgia have abnormal levels of brain chemicals called neurotransmitters. Specifically, they have low levels of serotonin, which affects mood, promotes sleep, and helps reduce the perception of pain. They often have high levels of substance P, which transmits the "pain message" to the brain.
• Disregulation of the autonomic nervous system -- The autonomic nervous system releases hormones that affect how you react to stress. Some doctors think people with fibromyalgia release these hormones differently when they experience stress, and the hormones affect the perception of pain.
• Sleep problems -- The majority of people with fibromyalgia report sleep problems, and especially have trouble with Stage 4 sleep, the most restful stage in which the body repairs itself. Some doctors believe that the lack of restful sleep means that the muscles of people with fibromyalgia are not able to repair the tiny tears and trauma that occur everyday, leading to muscle pain and fatigue. Other doctors believe that sleep problems are a result, not a cause, of fibromyalgia.
• Injury and infection -- Fibromyalgia can be triggered by an injury, especially to the upper spine or neck, or an infection caused by a virus or bacteria.
• Genetics -- The tendency to get fibromyalgia may sometimes be inherited.
• Having another rheumatic disease -- You may be more likely to get fibromyalgia if you have a disease such as rheumatoid arthritis or lupus.

What to Expect at Your Provider's Office

There is no laboratory test for fibromyalgia, but your doctor may order several tests, including blood tests and x-rays to rule out other diseases. Your doctor may also press firmly on specific "tender points" on your head and body to see which ones are abnormally sensitive under pressure. Be sure to tell your provider about all of your symptoms. You may be referred to a rheumatologist, who specializes in treating rheumatic conditions like fibromyalgia and arthritis.

Treatment Options

The goal is to help you function as well as possible on a day-to-day basis. While it is probably not possible to completely relieve all your symptoms, medication and certain complementary and alternative therapies may help reduce symptoms.

Drug Therapies

Your health care provider may prescribe the following drugs:

• Sleep disturbances are often treated successfully with low doses of tricyclic antidepressants, such as amitriptyline (Elavil), doxepin (Sinequan), and nortriptyline (Pamelor, Aventyl). Sometimes doctors may prescribe sleeping pills for short-term use.
• Analgesics treat pain. Your doctor may recommend non-steroidal anti-inflammatory drugs (NSAIDs), such as naproxen sodium (Aleve), ibuprofen (Advil, Motrin), or prescription NSAIDs. Sometimes these drugs may lessen pain, but they are not effective for everyone. Your doctor may also prescribe tramadol (Ultram), which is often used to treat fibromyalgia pain.
• Muscle relaxants such as cyclobenazaprine (Flexeril) can help treat muscle spasms.
• A technique called "spray and stretch" is sometimes used. A prescription spray coolant is applied to painful muscle while the muscle is stretched.
• Pain in specific spots in muscles can be treated with lidocaine or procaine (injected into points where pain is greatest) or with capsaicin (used topically). Ibuprofen may also help briefly reduce muscle pain.
• Depression can be treated with antidepressants, such as fluoxetine (Prozac) and sertraline (Zoloft).
• Armour Thyroid, a natural thyroid hormone medication, may be helpful if tests show abnormal thyroid function. People with fibromyalgia may want to have their tests examined by both conventional and holistically oriented physicians because levels of thyroid hormone in the blood are often interpreted differently. Specifically, people with fibromyalgia may want to ask for an assessment of T3 levels, a lab test often not done by conventional doctors (see the entry under "Hypothyroidism" for more information).

Complementary and Alternative Therapies

Nutritional support, exercise, herbs, and mind-body techniques may help reduce symptoms.

Nutrition and Supplements

• Eat a healthy diet. Eat fewer carbohydrates and more protein. Consume unsaturated fats in moderation. Eat plant-based foods such as vegetables, whole grains, fruits, plus essential fatty acids (cold-water fish, nuts, and seeds). Some people see an improvement by following a vegan diet (no animal products).
• Avoid alcohol and caffeine, and limit foods that are high in sugar, salt, and fat. Avoid foods with additives such as monosodium glutamate (MSG).
• If your symptoms seem worse after eating specific foods, try an elimination diet: Remove suspected allergens from the diet for 2 weeks. Reintroduce one food every 3 days. Watch for reactions such as gastrointestinal upset, mood changes, flushing, fatigue, and worsening of symptoms. Common allergenic foods are dairy, soy, citrus, peanuts, wheat, fish, eggs, corn, and tomatoes.
• Magnesium (200 mg two to three times per day) with malic acid (1,200 mg one to two times per day) may relieve pain and fatigue.
• S-adenosylmethionine or SAMe (800 mg per day) is often used as a therapy for depression, but the chemical may also have an effect on how the body uses energy. Some people report that taking SAMe helps decrease fatigue, stiffness, and pain, and improve mood. If you take a prescription anti-depressant, Ultram, St. John's wort or 5-HTP, talk to your doctor before taking SAMe.
• 5-hydroxytryptophan or 5-HTP (100 mg three times per day) may help with depression and insomnia. People with fibromyalgia often have low levels of serotonin, a brain chemical that influences mood and pain perception, and 5-HTP may increase serotonin levels. If you take a prescription anti-depressant, Ultram, St. John's wort, or SAMe, talk to your doctor before taking 5-HTP.
• Chlorella ( Chlorella pyrenoidosa ), a blue-green algae, may help lessen symptoms. Participants in the study took a specific dose of 10 g of Sun chlorella tablets and 100 ml of the liquid chlorella extract Wasaka Gold and showed significant improvement in symptoms. More studies are needed.
• Essential fatty acids, such as those found in fish oil (1,000 mg 3 time per day with meals) and evening primrose oil (3,000 - 6,000 mg per day, may also help reduce fatigue.
• NADH, a naturally occurring chemical involved in energy production in the body (5 - 20 mg per day), may help lessen fatigue.
• Coenzyme Q10 may help the body use energy and lessen fatigue (60 - 100 mg per day).
• DHEA, a hormone produced by the body that may improve energy levels (50 - 200 mg per day). DHEA is a precursor to testosterone and estrogen. It is truly a hormone rather than a supplement, and should never be taken without a doctor's prescription. Do not use DHEA if you have or are at risk for breast cancer, prostate cancer, or any other hormonally-influenced illnesses.
• Natural cortisol, a hormone produced in the body by the adrenal gland, has been used in some cases, in very low doses, for people whose lab tests show that their adrenal gland is not making enough cortisol. Because natural cortisol is a hormone, it can have serious side effects and should never be taken without a doctor's supervision.
• Melatonin (0.5 - 3 mg one time before bed) may help sleep. Talk to your doctor first if you are using any anti-depressants or other neurological or psychiatric medications.
• Zinc (30 mg per day) is essential for proper immune function. Taking zinc may make it harder for your body to absorb magnesium, so talk to your doctor before taking a zinc supplement.
• Quercetin (400 mg three times per day), a bioflavonoid found in many plants, may help reduce symptoms of pain and fatigue, but the evidence is anecdotal. Do not take quercetin if you take blood-thinning medication.
• Thiamin or vitamin B1 (1 - 2 mg per day) helps the body use energy. People with fibromyalgia sometimes have low levels of thiamin.
• For people who also experience restless legs syndrome, taking vitamin E (400 IU per day), folic acid (5,000 mcg per day), and magnesium may help. This is a high dose of folic acid and should only be taken under your doctor’s supervision.

Exercise

It may seem odd to suggest exercising when your muscles are sore and you are in pain, but a number of studies have shown that regular, low intensity exercise is one of the most effective treatments for fibromyalgia. Although you may experience a slight increase in pain and soreness when you start, as you continue you will help lessen muscle tension and stiffness, improve sleep quality, and raise serotonin and endorphin levels, helping to reduce pain. Many people with fibromyalgia find warm-water aquatic exercises to be helpful. Talk to your doctor or physical therapist to design an exercise program that is best for you.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted.

Herbal therapies aim to reduce the symptoms of fibromyalgia, or those of common conditions associated with fibromyalgia.

Muscle pain

• Capsicum or capsaicin, applied topically as a cream containing .025% capsaicin
• Devil’s claw ( Harpagophytum procumbens ), 750 mg three times per day
• Pycnogenol ( Pinus pinaster), 30 mg two times per day
• Ginger (Zingiber officinale), 100 - 200 mg in capsule form
• Cat’s claw ( Uncaria tomentosa ), 250 mg two times per day

Fatigue

• Ginseng ( Panax ginseng ), 100 mg two times per day

Sleep problems

• Valerian ( Valeriana officinalis ), 400 - 900 mg 2 hours before bedtime, often combined with lemon balm ( Melissa officinalis ). Note it may take 4 weeks to see any effects from valerian. Do not take valerian if you take prescription sleep aids.

Irritable bowel syndrome

• Slippery elm bark ( Ulmus fulva ). Use 1 oz. powder to 1 quart of water. Make a paste with the powder and a small amount of water. Gradually add in the rest of the water and then simmer down to 1 pint. Take 1 tsp. every 30 - 60 minutes.
• Chamomile ( Matricaria recutita), one to three cups of tea per day. To make tea, steep 3 g flower heads in one cup boiling water, strain, and cool.
• Enteric-coated peppermint oil, one to two capsules three times per day after meals. Do not take peppermint oil if you have liver disease or diabetes.
• See the entry under "Irritable bowel syndrome" for more information

Essential oils of jasmine, lemon balm, rosemary, and clary sage relieve stress and tension and may be used in aromatherapy. Place several drops in a warm bath or atomizer, or on a cotton ball, and inhale.

Homeopathy

Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual. Some of the homeopathic remedies used for fibromyalgia are below.

• Arnica -- for someone who feels sore and bruised, and does not want to be touched. Laying down is difficult, and they are restless when trying to find a comfortable position. Soreness stays after gentle exercise.
• Bryonia -- used when the slightest movement aggravates pain. The person is usually very thirsty. Pain is worse at night and upon waking in the morning.
• Calcarea carbonica -- for people who tend to move slowly, look pasty, and are always chilly. Exertion leaves them weak and breathless. They feel better when lying down. Being warm relieves symptoms.
• Rhus toxicodendron -- for joint stiffness, worse when starting to move then easing with more movement. Stiffness is worse in the morning and in cold or damp weather.
• Ruta graveolens -- for sore, bruised pain in the joints and tendons that feel worse when lying on the affected area.

Mind-Body Therapies

Stress makes symptoms of fibromyalgia worse, so mind-body therapies including meditation and biofeedback can be helpful in learning relaxation techniques.

Physical Medicine

Two to four cups of Epsom salts in a warm bath can soothe aching muscles.

Acupuncture

The National Institutes of Health recommends acupuncture as a treatment for fibromyalgia. Acupuncturists treat people with fibromyalgia based on an individualized assessment of the excesses and deficiencies of qi located in various meridians. In fibromyalgia, a qi deficiency is usually detected in the spleen or kidney meridians. Moxibustion (a technique in which the herb mugwort is burned over specific acupuncture points) is used to strengthen the entire energy system. Qualified practitioners may also advise people with fibromyalgia on lifestyle and diet, and provide recommendations on the use of herbal medicines.

Chiropractic

Because fibromyalgia generally includes low back pain or neck pain (for which spinal manipulation is beneficial), chiropractors commonly treat people who have this condition. In one small study, women with fibromyalgia reported that they experienced a 77% reduction in pain intensity, 63% improvement in sleep quality, and 75% improvement in fatigue level after receiving 30 chiropractic treatments. Symptom relief continued for 1 month after treatment ended.

Massage

Massage may reduce stress, improve circulation, and soothe sore muscles. Find a massage therapist who has experience working with fibromyalgia.

Following Up

Education and support groups may help you manage your condition.

Supporting Research

Abraham GE, Flechas JG. Management of fibromyalgia: rationale for the use of magnesium and malic acid. J Nutr Med. 1992;3:49-59.

Berman BM, Ezzo J, Hadhazy V, Swyers JP. Is acupuncture effective in the treatment of fibromyalgia? J Fam Pract. 1999;48(3):213-218.

Carr AC, Frei B. Toward a new recommended dietary allowance for vitamin C based on antioxidant and health effects in humans. Am J Clin Nutr. 1999;69(6):1086-1107.

Caruso I, Sarzi Puttini P, Cazzola M, et al. Double-blind study of 5-hydroxytryptophan versus placebo in the treatment of primary fibromyalgia syndrome. J Int Med Res. 1990;18:201-209.

Deluze C, Bosia L, Zirbs A, Chantraine A, Vischer TL. Electroacupuncture in fibromyalgia: results of a controlled trial. BMJ . 1992;305:1249-1252.

Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998:1955-1957.

Hains G, Hains F. Combined Ischemic compression and spinal manipulation in the treatment of fibromyalgia: a preliminary estimate of dose and efficacy. J Manipulative Physiol Ther . 2000;23:225-230.

Holland NW, Gonzalez EB. Soft tissue problems in older adults. Clin Geriatr Med. 1998;14:601-603.

Jacobsen S, Danneskiold-Samsoe B, Andersen RB. Oral S-adenosylmethionine in primary fibromyalgia. Double-blind clinical evaluation. Scand J Rheumatol . 1991;20:294-302.

Johnston CS. Recommendations for vitamin C intake. JAMA. 1999;282(22):2118-2119.

Kelley WN, ed. Textbook of Rheumatology. 5th ed. Philadelphia, Pa: WB Saunders Co; 1997:511-518.

Koopman WJ. Arthritis and Allied Conditions: A Textbook of Rheumatology. 13th ed. Baltimore, Md: Williams & Wilkins; 1993:1619-1635.

Leventhal, LJ. Management of fibromyalgia. Ann Intern Med. 1999;131:850-858.

McCarty DJ, Csuka M, McCarthy G, et al. Treatment of pain due to fibromyalgia with topical capsaicin: A pilot study. Semin Arthr Rheum . 1994;23:41-7.

Merchant RE, Carmack CA, Wise CM. Nutritional supplementation with Chlorella pyrenoidosa for patients with fibromyalgia syndrome: a pilot study. Phytother Res . 2000;14:167-73.

Nicolodi M, Sicuteri F. Fibromyalgia and migraine, two faces of the same mechanism. Serotonin as the common clue for pathogenesis and therapy. Adv Exp Med Biol. 1996;398:373-379.

NIH Consensus Statement: Acupuncture. National Institutes of Health, Office of the Director. 1997;15(5):1-34. Accessed at http://odp.od.nih.gov/consensus/cons/107/107_statement.htm on September 24, 2001.

Romano TJ, Stiller JW. Magnesium deficiency in fibromyalgia syndrome. J Nutr Med. 1994;4:165-167.

Rossy LA, Buckelew SP, Dorr N, et al. A meta-analysis of fibromyalgia treatment interventions. Ann Behav Med . 1999;21:180-191.

Russell IJ. Fibromyalgia syndrome: formulating a strategy for relief. J Musculoskel Med. 1998;November:4-21.

Russell IJ, Michalek JE, Flechas JD, et al. Treatment of fibromyalgia syndrome with SuperMalic®: a randomized, double blind, placebo controlled, crossover pilot study. J Rheumatol . 1995;22:953-958.

Tavoni A, Vitali C, Bombardieri S, Pasero G. Evaluation of S-adenosylmethionine in primary fibromyalgia. A double-blind crossover study. Am J Med . 1987;83:107-10.

Tyler VE. Herbs of Choice: The Therapeutic Use of Phytomedicinals. Binghamton: Pharmaceutical Products Press; 1994.

Wolfe F, Smyth HA, Yunus MB, et al. American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia: report of the Multicenter Criteria Committee. Arthritis Rheum. 1990;33:160-172.

• Review Date: 10/17/2006
• Reviewed By: Steven D. Ehrlich, N.M.D., private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

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