A 29-Year-Old Woman With Worsening Pain and Memory Issues

Caroline Tschibelu, MD


May 08, 2019

Fibromyalgia is best managed using a patient-centered, multidisciplinary approach initiated in the primary care setting.[18] Multiple studies have shown that the use of a combination of pharmacologic and nonpharmacologic therapies is the most effective approach to treatment and helps to control symptoms for many patients.[19,20] The goal is to reduce symptoms, improve quality of life, and help patients to regain the ability to perform ADL. Acknowledging the disease and showing empathy to patients suffering from fibromyalgia is important, as studies have shown that patients use health care resources to a lesser extent after they have been diagnosed and their illness, they feel, has been validated.[21,22] Patients should be well educated about their diagnosis and the active role they have in managing their symptoms, and should understand that fibromyalgia is a chronic condition that requires long-term management.

Important nonpharmacologic therapies include education on good sleep hygiene and a customized exercise plan. Exercise has been shown to decrease pain and help with general well-being.[23] Several studies have reviewed the efficacy of cardiovascular training, low-impact aerobic activities, and yoga, among other types of exercise.[24] Patients should be encouraged to gradually increase the amount of time that they exercise.

Drug monotherapy should be initiated if the nonpharmacologic approach is not sufficient. The medications that have shown efficacy for chronic pain include antidepressants and anticonvulsants.[25] Tricyclic antidepressants (TCA) are usually initiated first at a low dose taken at bedtime and titrated up as tolerated. They are effective at reducing pain, fatigue, and sleep disturbances.[26] They are also relatively inexpensive compared with other classes of medications. Most patients with fibromyalgia are started on amitriptyline; however, desipramine is an alternative tricyclic that has fewer anticholinergic side effects and less cardiotoxicity. For patients with moderate symptoms, cyclobenzaprine, a tricyclic-related medication and muscle relaxant, may be an acceptable alternative,[27] but it has minimal antidepressant effect.

Patients who do not respond to tricyclics or those who have depression may benefit from selective serotonin and norepinephrine reuptake inhibitors such as duloxetine,[28] venlafaxine, and milnacipran.[29,30] Duloxetine and milnacipran are approved for fibromyalgia; duloxetine has shown the most efficacy in clinical trials.

Anticonvulsants that have shown benefits for chronic pain include gabapentin and pregabalin; these are calcium channel modulators that block the release of neurotransmitters, thereby exerting their analgesic effects. They are also preferred in patients with severe sleep problems. In a 2009 meta-analysis by Hauser, five randomized, controlled trials on the treatment of fibromyalgia with gabapentin and pregabalin were reviewed and showed evidence of pain reduction, improved sleep, and improved health-related quality of life.[31]

Non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen have not been shown to be very effective for chronic fibromyalgia pain but can be used to manage acute flare-ups or nociceptive pain from comorbidities such as arthritis. Based on a few studies, tramadol is an analgesic that effectively improves chronic fibromyalgia pain. This may be due to its combined effect on mu opioid receptors and inhibitory effects on serotonin and norepinephrine reuptake;[32,33] however, tramadol is a narcotic and is addictive. Given the risk of addiction in patients with fibromyalgia, it should be used with caution, in limited doses, and only intermittently.

If symptoms persist with a single pharmacotherapy at the highest dose tolerated by the patient, a combination of drugs should be considered. Patients should also be referred to a rheumatologist or to other specialists, to manage a complex drug regimen or comorbidities. Depression should be treated aggressively, and patients should see a psychiatrist or may benefit from psychological intervention, including cognitive behavioral therapy, to help manage stress and anxiety. Additional treatments that can be considered include trigger point injections, acupuncture, physical therapy, and chiropractic treatment.

The patient in this case was started on low-dose amitriptyline at bedtime and tramadol as needed. She started exercising regularly and occasionally wears appropriate splints, applied as needed to relieve wrist pain. The patient reports that current management has improved her symptoms by approximately 80%, and her symptoms are well controlled most of the time.