Chapter 5: Treating Fibromyalgia: What you need to know
This chapter is devoted to a discussion about the core aspects of treatment options available to you. It is important to understand that this is by no means a comprehensive, definitive, and exhaustive listing of all treatment options available; it is merely meant to provide you with a starting point and steer you in the right direction. The truth is that potential treatment options are numerous, and the process of elimination to determine which one(s) are the most effective for you will be as individual as your fibromyalgia. As you read through these pages, understand that this is nothing more than a summary, meant to serve as a primary guide to help start you on your journey of learning about the treatment options available. It is well beyond the scope of this eBook to dig deeply into all of the possible treatment approaches. You can visit our website, www.fibromyalgia-treatment.com for a much more information on this.
Medical Specialists
It is important to assemble a well-rounded team of individuals to assist with your treatment. Your team will invariably include one or more medical specialists. With so many physicians out there, searching for one who is compatible with your needs, and who is also sympathetic toward and understanding of fibromyalgia may seem like a daunting task. Fortunately, there are resources available to assist you with your search. One way that you can start the process is to talk with fellow fibromyalgia patients; support groups are a great resource for this. Examples of online support groups as well as websites that contain directories of local support groups can be found in Chapter 1. In addition, some local chapters of the Arthritis Foundation offer physician referral lists for patients with fibromyalgia. The following are additional resources for locating physicians:
In order to build the most effective team, it will be important for you to screen and interview potential members to ensure that they have not only the right skills to contribute to your team, but the right attitude and understanding about fibromyalgia. When you meet with a medical specialist, be sure to ask for examples of success stories of former patients with fibromyalgia whom they have treated. In addition, ask them to discuss different treatment options they have used, and what the outcomes of those treatments were, along with any additional observations they made along the way (side effects, tolerability, patient feedback, etc.). Be sure to ask them what they think of the various alternative therapies that have been researched in relation to fibromyalgia – such as acupuncture, aromatherapy, and chiropractic.
When getting to know a new care provider, it is critical to not only evaluate their knowledge relative to treating fibromyalgia, but to also consider their general attitude and willingness to accept you as an engaged and active leader of your own care provider team. Take the time and make the specific effort to engage doctors and specialists in discussions about your approach to self management. Make sure they are willing to take the time to explain to you the logic and research behind why they recommend different treatment options. Make it clear that you wish to not only benefit from their expertise through their own opinions, but also through their providing feedback relative to your opinions and ideas. Communication and evaluation must be a two way channel.
One medical specialist that should be included on your team is a primary care physician. This can be an internal medicine doctor or a family medicine doctor. When choosing a primary care physician, it is vitally important that you find someone who is willing to listen to your concerns, ideas, and opinions, and who will take your input seriously. They must accept that you are the leader of your fibromyalgia management team. Be sure and choose a primary care physician who has experience with fibromyalgia patients, and who is knowledgeable of strategies to manage breakthrough pain.
The following is a non-exhaustive list of other medical specialists who you may wish to include on your team, along with a description of what they treat and various aspects of fibromyalgia that they may be helpful in managing.
- Rheumatologist: Rheumatologists are internal medicine physicians who have received additional training in the diagnosis and treatment of arthritis and other diseases of the muscles, joints, and bones. They commonly treat arthritis, autoimmune diseases, pain disorders, and osteoporosis. Many individuals with fibromyalgia may see a rheumatologist early in the course of their diagnosis in order to rule out arthritis and other musculoskeletal pain disorders. Since rheumatologists are specially trained to treat patients who have chronic pain conditions, they are often an integral part of a fibromyalgia patient’s treatment team.
- Psychiatrist: Psychiatrists are medical doctors who specialize in the prevention, diagnosis, and treatment of mental illness. They also monitor the effects of mental illness on other physical conditions, including heart disease and high blood pressure. Psychiatrists are well-trained to help patients who are suffering from depression and anxiety, both of which are extremely common among fibromyalgia patients. As medical doctors, psychiatrists can write prescriptions for medications that may be useful to fibromyalgia patients in managing their depressive symptoms.
- Psychologist: Psychologists are specialists who have received extensive post-graduate education in the assessment, diagnosis, treatment, and prevention of mental disorders. While not permitted to prescribe medication, psychologists treat patients through other means, including talk therapy, cognitive behavioral therapy, and behavior modification techniques. Psychologists can be instrumental in the care regimen of patients who are suffering from depression and anxiety by helping them recognize events that trigger or worsen their depression, and by identifying ways to cope with symptoms. Like psychiatrists, psychologists can be a vitally important part of a fibromyalgia patient’s care team.
- Neurologist: Neurologists are medical doctors who specialize in the diagnosis and treatment of diseases that affect the nervous system. Like rheumatologists, neurologists are often one of the first specialists seen by fibromyalgia patients on their quest for a diagnosis, as certain neurologic diseases must be excluded. In addition, the current understanding of fibromyalgia among many experts is that it results from the body’s inability to process painful stimuli correctly. Since nerves are the means by which the body transmits and processes pain, neurologists are often integral members of a fibromyalgia patient’s team.
- Chiropractor: Chiropractors are specially trained practitioners who focus on treating musculoskeletal and nervous system disorders. Chiropractors are not medical doctors, however they must complete four years of post-graduate training in a chiropractic college and pass both national and state licensing exams. Chiropractic care is commonly used to treat back and neck pain, joint pain, and headaches. Although research surrounding the usefulness of chiropractic care as a treatment for fibromyalgia symptoms is conflicting, some patients do find that chiropractic care improves their symptoms.
- Massage therapist: Massage therapists are specially trained practitioners who use therapeutic touch and pressure applied to muscles in order to relieve pain, rehabilitate injuries, reduce stress, provide relaxation, and relieve anxiety and depression. For fibromyalgia patients, massage therapy may be useful to help reduce pain and promote relaxation in an effort to improve depression and anxiety.
- Occupational therapist: Occupational therapists are specially trained, licensed healthcare providers who assist individuals who are experiencing difficulty with activities of daily living. They receive detailed training related to the physical and psychological difficulties associated with illness and the effects that these have on people’s ability to perform everyday activities. Occupational therapists modify an individual’s environment to fit their changing needs. This can obviously be beneficial to fibromyalgia patients, who are frequently forced to change the way in which they live as a result of the persistent pain they endure. Occupational therapists can help fibromyalgia patients modify their homes to better accommodate the physical limitations they face, which can result in improved symptom control.
- Dietitian: Registered dieticians are healthcare professionals who apply principles of food and nutrition to health and human functioning. They hold nutrition-related degrees that include studies in biochemistry, human anatomy, and physiology. They are also required to complete dietetic internships of at least 900 hours. In addition, dietitians are required to pass national board exams. Dietitians can be useful to fibromyalgia patients who suffer from many common co-existing symptoms and diseases, such as irritable bowel syndrome, obesity, and interstitial cystitis.
- Physical therapist: Physical therapists are licensed healthcare professionals who are trained in the diagnosis and treatment of movement disorders. They work with patients to improve the body’s functioning by restoring mobility, reducing pain, and preventing disability. Since fibromyalgia patients frequently suffer from decreased mobility as a result of their chronic widespread pain and stiffness, a physical therapist can be helpful in teaching patients how to overcome physical challenges they face.
- Naturopath: Naturopathic doctors focus on the holistic and proactive prevention of disease, as well as comprehensive diagnosis and treatment. Naturopathic physicians (N.D.) attend four years of post-graduate naturopathic medical school, during which they are educated in all of the basic sciences as medical doctors (M.D.); however, their studies also include education related to holistic and nontoxic therapeutic approaches, with an emphasis on disease prevention and the optimization of wellness. They are also required to complete four years of training in clinical nutrition, acupuncture, homeopathic medicine, botanical medicine, psychology and counseling, and they must also pass professional board exams. Naturopathic doctors may be useful members of a fibromyalgia patient’s treatment team.
- Holistic medicine practitioner: Holistic medicine focuses on addressing care of the whole person – body, mind and spirit. It integrates both conventional and alternative therapies in an effort to foster optimal health and wellbeing, and to prevent disease. Holistic medicine practitioners are useful to fibromyalgia patients because they focus on patient care in terms of the unique needs of the patient, rather than through a one-size-fits-all approach. The practitioner-patient relationship is viewed as a partnership that encourages patient input and needs. This individualized, attentive relationship can be of great benefit to fibromyalgia patients, as the disease itself is unique on the individual-level and requires a patient-directed approach to treatment.
As stated above, this is by no means a comprehensive list of medical specialists. There are many other medical disciplines. It is important to approach the building of your team with a receptive and inquisitive mind. Talk to others, get input and advice, and get creative. Fibromyalgia is an unique disease that requires a unique approach to treatment; have an open mind!
Create a Partnership with your Physician
When you have found a physician who meets your needs and who you feel is a good fit for your team, it is important to develop a productive relationship with him or her. The time limitations many doctors face when seeing patients – due to overloaded schedules, high patient-to-physician ratios, and other limited resources – underscore the need for you to be as prepared as you can at each appointment.
Below are a few tips to help you accomplish that:
- Prepare an agenda before your appointment. Know what you want to accomplish at that particular appointment. Do you need a diagnosis or an explanation of a new symptom? Do you need medication? Do you need paperwork signed by the doctor.
- Rehearse a brief but comprehensive description of your symptoms and situation before you visit the doctor so that you waste no precious time getting his or her input and assistance. Review your journals and notes and prepare which sections need to be shared. Take your journals and notes with you so your care provider can review them.
- Take an active role in your appointment. Describe your symptoms and concerns quickly and articulately. For example, you might say “Dr. Mills, I am here today because I’ve noticed my fatigue worsening. I’m worried that my exercise regimen may be affecting it, however my pain is much improved since I began exercising. I would like to discuss what options I might have to address my fatigue without sacrificing the pain relief I get from exercise.”
- Present to your doctor your ideas and theories about new treatment initiatives that you have researched and are interested in trying. Discuss the specifics of what you wish to try, why it appeals to you, research you have done into possible effectiveness, side effects, risks and problems. Share the thoughts from other care team members about your ideas. Make sure to express the value you place on your doctors thoughts relative to your own treatment ideas.
- As you converse with your doctor, be sure to leave the appointment with some concrete answers to key questions. Ask, "what is your diagnosis (i.e., what’s wrong?); what is your prognosis (i.e., what is the outlook?); what tests (if any) are needed; what treatments (both medical and behavioral) are advisable, and when you should return for a follow-up visit?"
- To make certain that you understand all that your doctor has told you, repeat back to him or her they key points they have told you. For example, you might repeat back that you understand that the doctor recommends you break up your exercise regimen into three 15-minute increments each day, rather than exercising for 45 minutes at a time.
FDA-Approved Pharmaceuticals
Three prescription drugs have now been approved by the U.S. Food and Drug Administration (FDA) to treat the symptoms associated with fibromyalgia: Lyrica, Savella, and Cymbalta. This next section will briefly describe these medications; for more detailed information on each, please refer to our website, www.fibromyalgia-treatment.com
Lyrica
Lyrica (pregabalin) is manufactured by Pfizer, Inc. and is approved by the FDA to treat neuropathic pain (pain that results from damaged nerves), pain due to shingles, and fibromyalgia pain. It can be also used to treat seizure disorders such as epilepsy. The means by which Lyrica works to treat fibromyalgia is not understood, however it is believed that it works by calming overactive nerves. Although Lyrica does not work for everyone with fibromyalgia, many patients have seen improvements in pain, sleep quality, and overall functioning.
Lyrica is taken as a capsule two to three times per day, usually at a dose of 300 to 450mg per day. The most common side effects of Lyrica include dizziness, headache, dry mouth, nausea, vomiting, constipation, gas, bloating, elevated mood, difficulty speaking, difficulty concentrating, confusion, forgetfulness, anxiety, loss of balance and/or coordination, twitching, increased appetite and/or weight gain, swelling of the arms and legs, and back pain. Allergic reactions are also possible, although rare. Individuals who have diabetes, women who are pregnant or nursing, or individuals on certain medications to treat high blood pressure should use caution when taking Lyrica.
Savella
Savella (milnacipran) is manufactured by Forest Pharmaceuticals, Inc. and is another FDA approved drug for treating fibromyalgia pain and improving overall functioning in fibromyalgia patients. While it cannot help everyone with fibromyalgia, Savella may help some individuals feel less pain and achieve improvements in overall functions.
Although it is not used to treat depression, it is in a class of medications that are commonly used to treat depression, known as selective serotonin reuptake inhibitors, or SSRIs. As such, Savella works by increasing the amount of chemicals that help stop the transmission of pain signals in the brain. SSRIs can cause unexpected changes in mood, particularly in younger patients, so it is important to understand that that your mental health may change in an unexpected way when you begin taking the drug. It is important to communicate any changes to your doctor immediately, and to make your family and other support group members aware of this potential risk.
Savella is taken in tablet form once or twice a day, preferably with food to minimize the risk of stomach upset. The most common side effect associated with Savella is nausea, however other side effects may include headache, constipation, dizziness, insomnia, hot flushes, excessive sweating, vomiting, heart palpitations, increased heart rate, dry mouth, and high blood pressure. Your blood pressure will need to be monitored by your doctor on a regular basis while taking Savella. Savella should not be taken by individuals who are currently taking medications known as MAOIs, or by those who have uncontrolled glaucoma (increased pressure in the eye). It is also important to let your doctor know if you have high blood pressure or any heart disease, liver or kidney problems, current or previous manic episodes or seizures, bleeding disorders, or are pregnant or nursing.
Cymbalta
Cymbalta (duloxetine) is FDA approved for the treatment of depression and generalized anxiety disorders, diabetic neuropathy (pain associated with diabetic nerve damage), and fibromyalgia pain. It can also be used to treat persistent bone or muscle pain from conditions such as osteoarthritis. Like Savella, Cymbalta is an SSRI and therefore works by blocking the transmission of pain signals in the brain.
When taken to treat fibromyalgia, Cymbalta is taken once a day as a long-acting (delayed-release) capsule. It is important that you do not crush, split, or chew the capsule; it must be taken whole. In addition, Cymbalta takes time to take effect, so the full benefit may not be felt for up to four weeks. Common side effects include nausea, vomiting, constipation, diarrhea, heartburn, stomach pain, decreased appetite, dry mouth, increased urination, sweating, dizziness, headache, weakness and/or tiredness, drowsiness, changes in sexual desire or ability, and uncontrollable shaking. Like Savella, individuals who take MAOIs should not take Cymbalta. Furthermore, certain blood thinners, antidepressants, diuretics and a variety of other medications can also interfere with Cymbalta, so it is crucial that you tell your doctor every medication and nutritional supplement you are taking or plan to take. Also tell your doctor if you are pregnant or plan to become pregnant, as Cymbalta can have adverse effects on the fetus.
Antidepressants
“Antidepressants” is a broad term used to describe a class of drugs commonly used to treat depression, anxiety, mood disorders, bipolar disorder, and other mental health problems. They work by increasing the body’s production of chemicals known as neurotransmitters. These chemicals transmit nerve signals within the brain and have effects on both emotions and pain reception.
There are four main types of antidepressants:
- Tricyclic antidepressants (TCAs): Among the first antidepressants used to treat depressive disorders, they primarily target two specific neurotransmitters in the brain: norepinephrine and serotonin. Although effective, they tend to cause a considerable number of side effects and are typically not used as a first line of treatment. Examples of common TCAs include Anafranil, Elavil, and Tofranil. Common side effects include dry mouth, vision disturbances, increased fatigue, weight gain, tremors, constipation, bladder problems, daytime sleepiness, increased heart rate, and sexual problems.
- Monoamine oxidase inhibitors (MAOIs): Another early class of antidepressants, they are most effective when used to treat people with depression who have not responded to other treatments. Unfortunately, MAOIs interact with substances in many foods and beverages, as well as a considerable number of other medications. As a result, patients who take MAOIs are limited to strict diets and medication regimens. Common examples of MAOIs include Parnate, Nardil, and Marplan. Side effects can be serious and include headache, racing heartbeat, chest pain, neck stiffness, nausea and vomiting. Certain foods and medications must also be avoided to prevent dangerous interactions.
- Selective serotonin reuptake inhibitors (SSRIs): These are a newer class of antidepressants and they work by modifying the available amount of the neurotransmitter serotonin in the brain. Some of the more common examples of SSRIs include Prozac, Zoloft, Paxil, Lexapro, and Celexa. Many patients treated with these medications will experience sexual problems (such as low sex drive or inability to orgasm), however such problems are reversible. Other side effects include dizziness, headache, nausea, insomnia, and a “jittery” feeling.
- Serotonin and norepinephrine reuptake inhibitors (SNRIs): Also a newer class of antidepressants, SNRIs increase the availability of serotonin and norepinephrine in the brain. Examples of SNRIs include Effexor, Remeron, and Cymbalta. Common side effects include drowsiness, blurred vision, feeling lightheaded, strange dreams, constipation, fever and/or chills, headache, changes in appetite, tremors, dry mouth, and nausea.
Prescription Sleep Medications
A number of prescription sleep medications are available for individuals who have difficulty falling or staying asleep (a condition known as insomnia). However, it is important to understand that if an underlying condition is causing the insomnia – such as fibromyalgia – treating that condition itself rather than treating the symptom of insomnia can ultimately be much more effective. Unfortunately that cannot always be achieved, as the Elusive Fiend can at times be difficult to manage, therefore making restful sleep next to impossible. In such instances, prescription sleep medications may be of benefit.
There are generally two types of prescription sleeping pills: those that help you fall asleep easier, and those that help you remain asleep for a longer period of time. Drugs that help you fall asleep include Lunesta (eszopiclone), Rozerem (ramelteon), Halcion (triazolam), Sonata (zaleplon), and Ambien (zolpidem). Drugs that are commonly prescribed to help you stay asleep include ProSom / Eurodin (estazolam), Lunesta (eszopiclone), Restoril (temazepam), Ambien CR (zolpidem), and Silenor (doxepin). In general, many of these drugs may interact with other medications, be habit forming, or can become less effective with prolonged use. Each drug has specific nuances that may make it a better choice for one person over another, so it is important to discuss each option with your doctor and decide which, if any, is best for you.
Anti-Anxiety Medications
The most common class of anti-anxiety medications those drugs known as benzodiazepines. While antidepressants are generally used over a long period of time to continuously treat and control depression and anxiety, benzodiazepines can begin working more quickly and therefore are ideal for short-term use in specific situations or in response to symptomatic episodes. Examples of benzodiazepines that are commonly used to treat anxiety include Klonopin (clonazepam), Ativan (lorazepam), and Xanax (alprazolam). The most common side effects of benzodiazepines include upset stomach, blurred vision, headache, confusion, grogginess, and nightmares.
Pain Management
Analgesic is the medical term used to describe any drug that is used to relieve pain. There are a wide variety of prescription analgesic medications available for pain management in fibromyalgia and other pain disorders. The following is a brief overview of selected examples:
- Narcotics: The most powerful type of pain-relieving medication is a class of drugs known as narcotics. Narcotics decrease pain by working on pain receptors found on the nerve cells themselves. Common examples of narcotics include Tylenol with codeine, Lorcet, Lortab, Vicodin, Morphine, OxyContin, Roxicodone, and Percocet. Excessive use of narcotics with other pain medications that contain acetaminophen (for example, Tylenol) can result in serious liver damage. In addition, narcotics can be very habit-forming, in addition to causing constipation, drowsiness, dry mouth, and difficulty urinating.
- Anticonvulsants: Anticonvulsants are medications generally used to treat seizure disorders such as epilepsy. However, several have been shown to have analgesic properties as well, including Tegretol (carbamazepine), Neurontin (gabapentin), Trileptal (oxcarbazepine), Lyrica (pregabalin), and Topamax (topiramate). Scientists do not fully understand how these anticonvulsants work to reduce chronic pain, but it is thought that they may actually disrupt the transmission of pain signals in the brain. The most common side effects of anticonvulsant medications include headache, dizziness, drowsiness, fatigue, confusion, skin rash, nausea, vomiting, loss of appetite, abdominal pain, weight gain or loss, and swelling of the feet.
- Muscle relaxants: Muscle relaxants are medications that control muscle spasms by depressing the central nervous system. They have a sedative effect on the body. In addition to calming muscle spasms, they can also relieve pain in some people. Examples of muscle relaxants include Soma (carisoprodol), Flexeril (cyclobenzaprine), Valium (diazepam), Skelaxin (metaxalone), and Robaxin (methocarbamol). They are not recommended for use by pregnant women, older adults, or those individuals with a history of depression or drug/alcohol addiction. Common side effects include drowsiness, dizziness, possible addiction, dry mouth, and urinary retention. To avoid the risk of developing dependence, muscle relaxants should be used only on a short-term basis.
- Anti-depressants: Although they have not been approved by the FDA to treat chronic pain, many antidepressants are commonly used to treat chronic pain conditions, such as fibromyalgia even when the patient does not have depression. Antidepressants have been shown to work best for pain that is caused by arthritis, nerve pain resulting from diabetes or shingles, migraine, fibromyalgia, low back pain, and pelvic pain. The way in which antidepressants treat the pain associated with these conditions is not understood, and it generally takes several weeks to achieve maximum results. The most effective group of antidepressants used for this purpose is the tricyclic group, which includes drugs such as Amitriptyline, Tofranil (imipramine), Anafranil (clomipramine), Pamelor (nortriptyline), and Norpramin (desipramine). Side effects commonly associated with the use of these medications include blurred vision, drowsiness, dry mouth, constipation, weight gain, difficulty urinating, and changes in blood pressure.
- Over-the-counter options: Common over-the-counter (non-prescription) pain medications, such as Tylenol (acetaminophen), Advil (ibuprofen), Aleve (naproxen), and aspirin. These are not specifically designed to treat fibromyalgia, but can be used to treat associated symptoms, such as headache and joint pain. Ibuprofen, naproxen, and aspirin can cause stomach upset, and all (with the exception of aspirin) can interfere with blood thinning medications.
Coping Strategies for Pain
It is important to have a variety of tools under your belt to help you cope with the pain associated with fibromyalgia. As your pain changes from one day to the next, so will your coping strategies. It is important to be flexible and open to a variety of options to help you better manage your pain. It is also important to remain positive and use your support network – friends, family, doctors, whoever you feel is the most appropriate person at that time – to lean on. Ask for help when you need it.
Distractions that divert your attention away from your symptoms are important coping mechanisms. Examples of distracting activities might include watching a funny movie, reading a short book, visiting with friends, engaging in a hobby you enjoy (if you can do so without aggravating your symptoms), or taking a slow, easy walk in a nice park. In addition, relaxation techniques can also be of tremendous help. Deep-breathing exercises, progressive muscle relaxation, meditation, yoga, and visualization can all be beneficial.
As with all aspects of fibromyalgia management, not every coping strategy will work for everyone, therefore it is important to remain open-minded, patient, and willing to explore a variety of options while searching for those that will become your mainstays for coping.
Dietary Supplements
A number of dietary supplements have been investigated as potential treatments for symptoms associated with fibromyalgia. Some have proven to be more effective than others, and effectiveness varies between individuals (i.e., what may be highly effective for one individual may have no noticeable effect in another). It is important to note too that dietary supplements may adversely interact with medications you are taking, so be sure and tell your doctor if you plan to use a dietary supplement so that you can be aware of any potential risks.
The list provided below is meant to provide an overview o
