Fibromyalgia is a condition that is managed by both medical treatments and lifestyle changes. Pain management in Fibromyalgia is a combination of multiple strategies, with medications as a last resort. For management of Fibromyalgia it is important to understand pain, the types of pain and the ‘pain cycle’.

Key Points

• Persistent pain is a core symptom of Fibromyalgia
• Pain management is breaking the cycle by understanding pain triggers and windup
• Like other symptoms, pain levels can be linked to physical stressors, infections, immune factors, as well as activities
• Patients need to monitor pain and respond – adjust lifestyle, food, environmental and other triggers
• Optimal pain management involves many non-drug strategies
• Pain management is a combination of multiple strategies, with medications as a last resort
• Note that addressing fatigue and poor sleep can reduce pain

Understanding Types of Pain in Fibromyalgia

Persistent pain in the neurological condition Fibromyalgia, whether widespread, migratory or localised, peaks and wanes and may range from mild to severe.

Pain reflects inflammation in the brain and spinal cord and can be in muscles, joints or both. As part of diagnostic criteria, pain is located in all four quadrants of the body, upper, lower, left and right sides.

Headaches may be particularly troublesome, they can be a new type, pattern or severity and are often migraines.

Both nociceptive pain and neuropathic persistent pain are experienced in Fibromyalgia: these mirror damage to the nerves and cells and are similar to the pain experienced in shingles and diabetes.

Three types of Fibromyalgia pain are medically defined:

• Hyperalgesia – Is the body’s exaggerated response to pain stimulus
• Allodynia – A clinical situation that results in pain from a stimulus (such as light touch) that normally should not be painful
• Painful paresthesia – Odd nerve sensations that can feel like crawling, tingling, burning, itching, or numbness

Common Patient Terminology

• Aching
• Burning
• Throbbing
• Stinging
• Crawling

Pain Cycle

Unmanaged persistent physical pain can create a cycle of the worsening of many symptoms of Fibromyalgia.

Pain management in Fibromyalgia aims to break the pain wind-up cycle at any of the cycle steps by linking pain initiators, triggers, sustainers and co-existing conditions.

Before care plan interventions and wider referrals, it is important to treat localised pain, e.g. arthritis or migraine, because it can hinder progress and amplify the generalised pain of Fibromyalgia and can spiral out to other symptoms.

Helpful non-pharmacologic interventions

Helpful interventions may include the following, however, should be approached with caution, as they may also be poorly tolerated, inaccessible, or prohibitively costly.  These approaches can be effective singly or in various combinations using the start low go slow, one at a time approach.

• Pacing of activity
• Individually tailored physical therapy
• Movement/exercise within personal limits
• Meditation (relaxation response)
• Myofascial release
• Trigger point therapy
• Acupuncture
• Hydrotherapy
• Massage
• Stretches
• Yoga
• Tai Chi

Also consider:  Hot or cold packs, warm baths, muscle liniments, electrical massagers, TENS (transcutaneous electrical nerve stimulation), and rTMS (transcranial magnetic stimulation).

Cautions:

• Changes in pain levels or new pain experienced must be followed up and not ignored
• Medications are used as a last resort for the treatment of pain in Fibromyalgia, the lowest effective dose should be prescribed and increased cautiously
• Patients with severe pain may need the stronger analgesics and narcotics. Referral to specialist pain services may be necessary

Key points

• Like other symptoms, pain levels can be linked to physical stressors, infections, immune factors, as well as activities
• Patients need to monitor pain and respond – adjust lifestyle, food, environmental and other triggers
• Optimal pain management involves both pharmacological and non-pharmacological interventions

PATIENT SELF MANAGEMENT STRATEGIES

• Monitor pain: identify triggers and plan to manage them, e.g. identify tasks that increase pain, and identify which of these can be eliminated or delegated.
• Observe patterns in the pain – does the pain fluctuate? This is important for determining whether the pain is responding to medication or whether the change has a different cause.
• Pace activity levels – keep moving as much as possible within daily limits.
• Assess the response to one class of medication before moving onto the next class e.g. Ibuprofen works more effectively when taken regularly to relieve severe pain, rather than when using it only at a crisis.
• Manage emotions – depression lowers the threshold of pain. Become aware of negative self-talk and replace it with pleasurable thoughts.
• Communicate clearly to the GP about the priority of pain related symptoms, and about any observations and links to pain levels.
• Take longer-acting medication at bedtime.