Fibromyalgia

For most people with fibromyalgia, medications have minimal impact on their symptoms. The benefits of the medications are often outweighed by their side effects. Non-medication treatments and self-management are the preferred first step for managing this disease and should be the focus of treatment.

Self-Management

There is no single treatment that works for everyone. Over time, most people with fibromyalgia will find the balance of treatments that gives them the best relief. Eliminating all symptoms is rarely possible, but a management plan can help you contain your symptoms so that you can lead an active and enjoyable life.

Your first and most important step is to become an active participant in your treatment and develop coping strategies to manage your fibromyalgia. It is also important to learn more about your condition and share that information with family and friends, so they can understand how you feel physically and emotionally.
Self-management of fibromyalgia includes the following components:

• Education about the condition
• Physical activity
• Sleep strategies and fatigue management
• Mental health management (including stress management and psychological therapies)
• Eating well

Physical Activity

The best evidence-based approach for improving symptoms of fibromyalgia is maintaining regular physical activity. Although pain and fatigue can make exercise difficult, it is important to keep physically active. Movement and physical activity may help to retrain the brain to accurately process symptoms and signals from the environment.

People with fibromyalgia may experience muscle stiffness. This stiffness cannot be reduced by rest. On the contrary, inactivity can cause muscle weakness and worsens the stiffness. Regular physical activity can reduce pain and fatigue, improve mobility and sleep issues, and help alleviate symptoms of depression. Overall, it can help someone with fibromyalgia to function better and lead a more enjoyable life.

A movement program designed for you by a professional is ideal. However, there are many ways to stay active including participating in a community-based program. It’s best to find something that you enjoy that you can do consistently. Exercise should be done within your tolerance and not pushed to the extreme. Each person with fibromyalgia will enjoy and tolerate activities differently, so it may take some time to find something that works for you.

When exercising, it is important to always listen to your body and use a graded “start low and go slow” approach. Exercise may initially result in increasing pain or discomfort as your tissues and nervous system adapt to this change. Find the amount of activity that you can do consistently and then gradually increase the demands of this activity over time.

For example, if your walking tolerance is 20 minutes, try walking for half that time, 10 minutes, consistently. Once you can consistently walk for 10 minutes, then increase to 11 minutes and so on.

There are different types of exercises you can do to lessen your pain and stiffness:

• Range of motion: Also called stretching or flexibility exercises, these help to keep your body moving regularly to reduce pain and stiffness. Ideally, these exercises should be done daily.
• Strengthening: Exercises that maintain or increase muscle tone. These exercises include weight training movements that can be done with your own body weight, or with a set of “free” weights or with a weight machine. Strength exercises can be done three or four times a week.
• Endurance: Exercises that strengthen your heart, give you energy, and help improve your overall health. These exercises can also help with weight management if that is something you’re working on. Endurance exercises include walking, swimming and cycling. Health Canada recommends aiming for 150 minutes of cardiovascular activity a week. Although this may seem daunting, the time can be broken down into smaller increments that you can gradually increase as able.
• Tai chi or Qigong: These ancient Chinese mind-body practices combine gentle movements performed in a slow, focused manner along with controlled breathing and meditation. Though they have many variations and styles, they can offer low impact physical activity. Tai chi can reduce pain and increase physical function in some people, as well as reduce symptoms of depression and contribute to health-related quality of life.
• Yoga: This mind-body practice originated in ancient India and modern studies have shown some benefits of yoga for people living with fibromyalgia. The practice of breath control, meditation and gentle movement can improve your state of mind and help you better manage your pain. Regular yoga under the guidance of a certified instructor can also boost your general health and increase your energy levels.
• Water exercises: These include activities such as swimming, water walking, and water aerobics. They are excellent for people living with fibromyalgia and suitable for all ages and fitness levels. Warm water can help you move in ways that would otherwise be painful. Water exercises can help improve your sleep and help to alleviate stress and symptoms of depression that are sometimes linked to fibromyalgia.

It is important to note that regular physical activity – at a comfortable level – is good for your overall health and will not cause you harm or damage to your body. Keeping a diary over several weeks can be a good way to encourage yourself to keep up a regular routine. A diary can also help you keep track of the connection between your fibromyalgia symptoms and your daily activities, which can help you and your health care team manage your fibromyalgia.

To learn more about staying active with chronic pain and fatigue, including a curated list of our physical activity and exercise videos, visit our Physical Activity Guide.

Sleep Strategies

Fatigue is a key symptom of fibromyalgia, so getting enough good quality sleep is important when it comes to managing your condition. Sleep can help to decrease both the fatigue and pain that may occur with fibromyalgia. It is also important that you do not spend extended hours in bed as too much rest and sleep can also be harmful to you both physically and emotionally.

Tips to help you get a good night’s rest:

• Go to bed and wake up at the same time each day.
• Develop a regular routine to help you wind down before bedtime.
• Avoid caffeine in the evening (including soft drinks, coffee and caffeinated tea).
• Avoid smoking.
• Avoid watching TV or using electronic devices (such as mobile devices and laptops) late at night.
• Ensure your bedroom is dark, quiet and a comfortable temperature.
• If you are having difficulty sleeping despite using the above strategies, consider programs that involve Cognitive Behavioural Therapy (CBT) strategies for sleep or speaking to your primary care provider.

Fatigue Management

Being tired, low in energy or fatigued is a common problem with fibromyalgia, arthritis and other chronic conditions. It can make it difficult to concentrate or deal with pain and sometimes it can make you feel helpless. Fatigue can be due to pain, poor sleep, depression, or other factors. Therefore, it is important to address these factors when trying to manage your fatigue. Fatigue can improve with regular exercise.

Taking action to increase your energy and minimize your fatigue will help you feel better and be active. The “5Ps” of fatigue management provide some guidance for how to adapt our daily activities to manage with limited energy:

• Pacing: How can you break activities into smaller tasks and take your time? Break your activities down into doable parts and spread them throughout the day or week, and take short, regular breaks before you start to feel tired.
• Planning: What are the steps you need to take to do the activity? Make a plan of the things you want to achieve during the day or over the week. Plan how and when you’re going to do certain tasks. Make sure that demanding jobs are spaced out through the day or week.
• Prioritizing: What needs to be done and by when? If you list the tasks you need to do, you can list them in order of importance and decide what task you can remove, delay or hand over.
• Positioning: How should you hold your body during the activity? Maintain an upright position when sitting and standing. You can use tools to help support these postures.
• Problem Solving: Can you do an activity in a different way? Look at your daily routine and notice how you feel when you spend part of your day doing the same type of repetitive tasks. If something you are doing causes you a problem, ask yourself how you can do it differently.

Mental Health Management

Living with fibromyalgia and chronic pain can have significant emotional impact on your life and the lives of those close to you. It may also impact your work and leisure activities.

The invisibility of the pain and fatigue, the unpredictability of how you might feel from day to day, and the lifestyle changes that may be necessary can have a considerable effect on you and your relationships.

You may be feeling emotions such as anger, denial, disbelief, guilt, fear, frustration, irritability, loneliness, and isolation. These are all normal feelings. It is important to talk about your feelings. Let loved ones know that you need their support in coping.

Stress Management

Stress is a normal part of life, but it may amplify the pain response and make your symptoms worse. It is impossible to avoid or eliminate all stressors. Sources of stress may include living with chronic pain, the pressures of daily responsibilities, life changing events (positive and negative), and many other factors. There are several techniques that may help to reduce stress and decrease the “fight or flight” response. These techniques include:

• Meditation: a mind-body practice intended to quiet the mind by focusing on your breathing. Meditation has been practiced for millennia and some modern studies have found that meditation, if practiced regularly, can ease pain and anxiety in individuals with fibromyalgia. It can also offer people a heightened sense of calmness and control.
• Breathing techniques: can help you learn to control your breath, promoting a sense of relaxation and safety. These techniques may include deep diaphragmatic breathing, guided and paced breathing.
• Biofeedback: a mind-body technique that involves using sensors to monitor physiological responses, like breathing patterns and muscle responses, providing real time feedback and helping you learn to control these responses.

Psychotherapy

Counselling can help with issues that may be unresolved or ongoing and affecting stress and pain levels. Speaking to your health care provider about the need for counselling is a good first step.

Cognitive behavioural therapy (CBT) is a type of psychotherapy that helps people manage their mental health by changing negative thought patterns and behaviours. It focuses on the present and aims to equip individuals with coping strategies to address current problems and improve emotional regulation. Cognitive behavioural therapy can help you find healthier ways to disrupt unhelpful behavioural patterns that may worsen your situation and contribute to feelings of anxiety and despair.

Acceptance and commitment therapy (ACT) is another form of psychotherapy that has shown some promise in the treatment of fibromyalgia. It focuses on accepting difficult thoughts and feelings rather than trying to suppress or change them. It uses mindfulness and commitment to action to help individuals live a more meaningful life aligned with their values, even in the face of challenging experiences.

Visit our Mental Health resource to learn more about stress, common mental health conditions, self-management strategies, and where and when to seek help.

Eating Well

Eating well will give you the energy to complete your daily activities as well as contribute to a strong immune system, and bone and tissue health.

Although no one specific diet has been proven to help fibromyalgia, there is some evidence to suggest the Mediterranean Diet, low FODMAP diet, or plant-based diets may help relieve fibromyalgia and pain. Obesity can also contribute to increased pain in a person with fibromyalgia. While further research is needed, managing a healthy weight may help in the management of fibromyalgia. Eating well looks different for everyone, and the most important thing is making food choices that work for your body and your situation.

Three ways to improve your nutrition include:

• Reduce sugar intake: High intake of added sugars can cause spikes in blood sugar and contribute to inflammation, especially when consumed regularly. Sugar refers to white, brown, cane and raw sugar as well as syrup and honey. Try using dried fruits such as raisins or dates to sweeten food since they provide vitamins, minerals and fibre. Although artificial sweeteners contain few calories, it is better to minimize their use and try to get used to food being less sweet. You may also want to check food labels for hidden added sugars.
• Eat more vegetables and fruit: Vegetables and fruit should make up the largest component of your diet. Try to have at least one vegetable or fruit at every meal and as a snack. Besides being an excellent source of energy, vegetables and fruit boost your fibre intake. Fibre supports digestion, blood sugar balance, cholesterol control, and helps you feel full longer.
• Choose “healthy fats”: The type and amount of fat you eat is important. You need some fat in your diet, but too much can be bad for your health. Some types of fat (saturated and trans fats) may increase your risk of developing heart disease. Polyunsaturated and monounsaturated fats are recommended as the main source of fat in your diet. Monounsaturated fat is found naturally in olive and canola oil, avocadoes and nuts like almonds, pistachios and cashews. Polyunsaturated fats, especially omega-3 and omega-6 fatty acids, can be found in cold-water fish (such as char, mackerel, salmon and trout), walnuts, sunflower seeds and flaxseeds. Fats that should be limited include trans fats, which are found in fried and processed foods, and saturated fats, which mainly come from animal sources of food, such as red meat, poultry and full-fat dairy products. Consider choosing lower fat dairy products such as skim, 1 or 2% milk, low-fat yogurt and low-fat cheese.

Visit our Eating Well resource for more information and strategies to help you make food choices that align with your individual needs, preferences, and lifestyle.

Complementary Therapies

People with a chronic condition like fibromyalgia may decide to try complementary and alternative therapies to help them manage the symptoms of their condition.

Before you try any of these treatments, always inform your health care provider of any complementary and alternative therapies you are taking, receiving or would like to try. They can offer valuable advice about these treatments, especially how they may affect other medications and treatments.

Massage

Massaging of muscles and other soft tissues by a professional massage therapist may lead to a short-term decrease in stiffness and pain. Other benefits may include a reduction in stress and anxiety as well as improved sleep patterns.

Acupuncture

Acupuncture is an ancient practice based in Traditional Chinese Medicine. It can be used for alleviating pain and treating various physical and mental health conditions, and involves pricking the skin with needles. While studies on the effectiveness of acupuncture for fibromyalgia symptoms are somewhat mixed, you may wish to try this treatment. It is important to find a certified practitioner.

Emerging Treatments

There are multiple emerging treatments that are showing promising results for people with fibromyalgia that doesn’t respond well to other treatments. Some of these approaches include vagus nerve stimulation, transcranial direct current stimulation and hyperbaric oxygen therapy. More large-scale, long-term studies are needed to confirm whether these approaches are effective and refine protocols. Talk to your primary care provider for individualized guidance.

Medication

Unfortunately, there is no single effective medication for all people living with fibromyalgia. Instead, you and your doctor should identify the symptoms that cause you the greatest distress before deciding if a medication may be helpful. For most people, these symptoms include pain, sleep disturbance, mood disorders, and fatigue. Self-management strategies should always be used in conjunction with medication. Part of your conversation should also include an informed consideration of the balance of the potential risks and benefits of medications, in both the short- and long-term.

Medication for fibromyalgia is often given on a trial basis. It is important for you and your doctor to decide whether a new medication has had a sufficiently positive effect to justify continuing the treatment. If the positive effect is only minimal, or if there are side effects of the medication, then that medication should probably be discontinued and a new medication tried.

Two medications have been approved by Health Canada specifically for treating the symptoms of fibromyalgia: pregabalin, which is an anti-convulsant drug that may improve pain and sleep, and duloxetine, an antidepressant drug with pain-modulating effects.

Your doctor may also prescribe other medications that have been available for many years for other conditions (“off-label”). Please discuss the use of any medication with your health care provider.

Anticonvulsant Medications

This category of medications reduces pain by decreasing the activity of nerves that are in overdrive due to fibromyalgia. They work like the dimmer switch for a light bulb. The most common anticonvulsant medications used in fibromyalgia are pregabalin and gabapentin (off-label). Their most common side effect is sleepiness. This can be an advantage when the medication is taken at night to help with sleep disturbances but can be troublesome during the day. If combined with alcohol or tranquilizer medications, however, the negative effect of unsteadiness or sleepiness may be exaggerated and could lead to harm.

Antidepressant Medications

Antidepressant medications can be used to control pain and have shown some success in treating pain symptoms in fibromyalgia. Antidepressants act on pain by boosting the body’s natural mechanisms for reducing pain. Tricyclic antidepressants were the first medications recommended for the treatment of fibromyalgia and still remain a useful drug for some people. They have been used for many years and are fairly inexpensive. Tricyclic antidepressants may help the symptom of poor sleep as well as pain. Newer antidepressants belong to the group of serotonin norepinephrine reuptake inhibitors (SNRls). Duloxetine falls into this category. Studies have found that SNRls may have some modest effect on pain, fatigue and mood in some people with fibromyalgia.

Many people with fibromyalgia also experience symptoms of depression or anxiety. If these symptoms are severe enough that they affect your wellbeing, your doctor may decide to prescribe a medication to improve your mood. Depending on the antidepressant medication chosen, there may be the added effect of calming anxiety, promoting sleep or improving energy.

Pain-Relieving Medications

For most people with fibromyalgia, pain-relieving medications, such as analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) will have minimal impact on pain. They may be used occasionally at a low dose for a short period of time when symptoms worsen, as long as there are no other health conditions that prevent you from doing so.

Acetaminophen is considered a mild pain reliever that may take the edge off fibromyalgia pain. This medication should be used only at the lowest dose and for as short a period of time as possible, as it may have potentially serious effects on liver function.

Although opioid medications such as tramadol have been used in the past for fibromyalgia, the current research indicates that it is best to avoid them since they are less effective and carry serious side effects.

Other drug treatments currently being investigated for use in fibromyalgia include:

• Low dose naltrexone (LDN): Naltrexone is a medication primarily used for treatment of alcoholism and opioid use disorder. When used in a low dose, it may improve fibromyalgia symptoms but more research is needed.
• Muscle relaxant: The muscle relaxant cyclobenzaprine has been available for many years, but recently studies of a low dose cyclobenzaprine given under the tongue have shown promising results.
• Cannabis: Cannabis may be an effective and safe treatment for people with fibromyalgia for whom the standard treatments did not work and who have sleep disorders. Further studies are needed to see the long-term impact and effect of cannabis. Caution should be used in patients with underlying psychological conditions since cannabis use has been linked to higher incidence of psychosis and schizophrenia, memory impairment, developmental and cognitive disorders.

Visit our Medication resource for more information about using medication as part of your treatment plan. Our Pain Management Guide includes information and tools to help you better manage pain symptoms.