Management of fibromyalgia

Despite extensive clinical study, there is no distinct consensus on the optimal management of fibromyalgia. The cause of fibromyalgia has not been clearly defined, but several mechanisms may be involved. Abnormalities in sleep patterns, muscle structure, and cerebral blood flow have been associated with the syndrome, but it is unclear whether a causal relation exists between these abnormalities and fibromyalgia. Recent evidence suggests that alterations in the metabolism and function of the neurotransmitters serotonin, norepinephrine, and substance P may contribute to the development of fibromyalgia. No pharmacologic agents are indicated specifically for the treatment of fibromyalgia in the United States, and most pharmacologic therapies show only limited success, although drugs that affect serotonin or norepinephrine at the receptor site (such as antidepressants or tramadol) seem to generate the most consistent results. Tricyclic antidepressants may diminish the sleep disturbance and pain caused by fibromyalgia, whereas selective serotonin reuptake inhibitors may be more useful for sleep and coexistent depression only. Among the commonly used analgesics, preliminary data suggest that tramadol may be useful for treatment of fibromyalgia pain and that trigger-point injections may be helpful. Controlled trials of antiinflammatory agents have demonstrated little usefulness of these drugs, and oral opioids have not been studied for this condition. Miscellaneous agents, such as growth hormone, tropisetron or ondansetron, 5-hydroxytryptophan, gamma-hydroxybutyrate, and S-adenosyl-L-methionine, have also shown promising preliminary results, but their clinical roles remain to be defined. Nonpharmacologic interventions (such as exercise, biofeedback, and electroacupuncture) have likewise shown some success. Therefore, a multidisciplinary approach that includes both pharmacologic and nonpharmacologic strategies is recommended.