There is no “cookbook” way to treat a person with fibromyalgia (FM). First, other “hidden” disorders need to be identified and treated. Then sleep needs to be targeted. Pain specialist Steve Fanto, M.D., of Scottsdale, AZ, says, “The key is to be flexible when managing a patient with FM. Doctors can’t have one or two drugs in their bag of tricks, because they will probably fail with their treatment of FM patients.”
“I view FM as a disruption of the pain system,” says David McLain, M.D., of Birmingham, AL, but he also tames an immune system primed to make you hurt more. “I have treated close to 500 FM patients with low-dose naltrexone and seen remarkable improvement.” McLain also uses tizanidine to improve sleep while reducing muscle tightness. He finds combo meds used in tiny doses work best (Summer 2012 Fibromyalgia Network Journal).
Donna R. Kesselman, M.D., of Manhattan, NY, agrees, saying, “‘Less is more’ when treating FM patients.” She prescribes Neurontin, opioids, and dopamine-enhancers; drugs which minimize the transmission of signals going to the brain that are interpreted as pain. “If pain, sleep, and muscle tension can be improved, the fatigue will lessen and the fibro fog will ‘lift,’” adds Kesselman (Spring 2012 Journal).
Targeting the Muscles
Do you wonder why you are so tender to the touch? You are not alone, because 90% of your tender points are actually trigger points. Research by Hong-You Ge, M.D., Ph.D., of Denmark (January 2010 Journal) explains how those tight, rope-like muscles with painful nodules not only hurt where you can feel them, but also radiate pain throughout your body. The good news is there are many treatment options.
Various nondrug therapies can ease muscular discomfort because medications are seldom enough. In each Journal, read about self-help techniques or photo-illustrated approaches for getting FM under control. Examples include reducing pain around your hips and low back, getting your neck and shoulders to relax, and fibro-friendly ways to stay fit.
Getting Good Sleep?
If you spend eight hours in bed, but still wake up feeling like you’ve been run over by a Mack truck, your body isn’t getting the rest it needs to restore itself.
Better sleep can do more than improve your pain, it can benefit your cardiovascular system and help you lose weight, explains Janet Mullington, Ph.D., of Harvard (April 2009 Journal). Poor sleep impairs optimism and mood, while the timing of your meals can shift your bedtime and cause weight gain (Summer 2012 Journal). Florian Chouchou, Ph.D., of France (July 2011 Journal), explains how a tiny amount of pain arouses the brain and destroys sleep in healthy people. The situation is worse for unrelenting FM pain, but strategies for minimizing sleep disruption can leave you feeling refreshed.
Don’t get stuck in a rut when your doctor only offers the three FDA-approved drugs to treat your FM (Lyrica, Cymbalta, and Savella). Alan Spanos, M.D., of Chapel Hill, NC, wants patients to be aware that, “FDA-approval doesn’t mean ‘best in show’” (April 2010 Journal). Know what the odds are that a drug will work and its most likely side effects before trying it. Get our Fibro Meds Pack and Top 25 Chart for the most up-to-date information. See the Special Issues section for details.
Stimulating medications may help, but not always. Sometimes the best approach involves changing your diet and adding nutritional supplements, like co-enzyme Q10, to give you a mental and physical lift. Our Diet and Nutrition Special Issue gives you many options for improving your energy and relieving other FM symptoms.
There’s so much more to FM than pain! If you can get a better handle on what causes your various symptoms, you will be more successful with getting them treated. Get our publication, Why You Have So Many
Symptoms, and start receiving the care you deserve. See the Special Issues section for details.
Having trouble getting family and friends to understand your fibromyalgia (FM) is a very common problem. There is no reason to feel guilty because you have to cancel out on attending an event, or you need to rest. Be up front and honest with family members about your FM. See our Special Issues section (next page) for help with Relationships. Here are a few survival tips:
“When approaching a pain patient, I try to think of what other conditions could be underlying their widespread symptoms,” says Lucinda Bateman, M.D., who runs a clinic specifically for people with chronic fatigue syndrome (CFS) and fibromyalgia (FM) in Salt Lake City, UT. “For example, if a patient has osteoarthritis, that part of their pain will respond to anti-inflammatory medications, and you want to distinguish it from the FM.”
Speaking at the International Association for CFS in Reno, NV in March, Bateman spoke to her colleagues about pain and how to “peel away the layers of an onion” to identify the various sources and treat them.
Unlike the carefully selected patients who participate in research studies, Bateman says that the patients walking into her clinic have more symptoms and a variety of other medical conditions. When FM is present, all of the incoming pain signals going to the brain are magnified regardless of whether they are caused by tissue inflammation, a pinched or irritated nerve, an infection, or too much physical or mental stress (see diagram). To make matters worse, the brain’s pain inhibitory system that descends to the spinal cord to blunt incoming signals is defective, so incoming signals become amplified and even light touches can be painful.
To help doctors identify the various sources of your pain, Bateman suggests that at each visit, patients mark a body diagram pinpointing pain. “It saves a lot of time and conversation.” If there is radiating pain from a nerve on one side (single nerve compression or injury), or in the nerve endings of the feet (a peripheral neuropathy), a regional muscle pain, a joint problem, or enhancement of the widespread pain of FM, the diagram will look different. “Every potential area that can have pain may show up for a person with FM, and clinicians must be prepared. So you can look at a pain diagram and make a few quick decisions on what questions to ask about your patient’s pain.” The Brief Pain Inventory diagram can be downloaded from the Internet.
Treating Different Pains
“Each pain condition has its own specific set of effective or partially effective therapies that might reduce the impact of FM,” says Bateman. “Don’t just lump all of these pains with the FM. Patients can become over-medicated when pain is just viewed as a single package instead of being teased apart into its contributing components.”
Cervical or lumbar disc disease with nerve compression may respond to anti-epileptic drugs (AEDs) like Lyrica, but physical therapy, local procedures, or surgical interventions might rectify a situation. Carpal tunnel syndrome (wrist pain), bursitis, tendinitis, plantar fasciitis, and bone spurs may all be irritated by repetitive motion that is eased by anti-inflammatory drugs, which are not effective for FM. There are other options as well, says Bateman. “The patient can wear a brace, get a steroid injection, or there could be a surgical solution.”
Irritable bowel syndrome, interstitial cystitis and endometriosis are just a few abdominal or pelvic pains that may be present in people with FM. “Each of these conditions has its own specific set of treatments that might eliminate or reduce that pain,” says Bateman.
“Daily headaches and migraines deserve a very focused approach and special treatment.” Myofascial trigger point therapies can ease tension headaches (April 2007 Fibromyalgia Network Journal), and there are preventive medications for migraines. If your FM patient has frequent migraines, Bateman says, “You might want to prescribe Topamax (topiramate). It must be dosed very carefully to avoid common debilitating side effects (e.g., fatigue, nausea, diarrhea, trouble concentrating). Start low (12.5 mg) and build very gradually (12.5 mg every one to two weeks), with the largest dose at night and little or none in the morning. Topamax may control the migraines, get your patient sleeping, and work as a mild pain modulator to minimize the FM during the day.” Trileptal (oxcarbazepine) and Neurontin (gabapentin) and other AEDs may also help with migraines.
Generalized FM Pain
So far, the focus has been on identifying and treating the regional pains that become amplified by the FM. But what can doctors do specifically to treat the generalized FM pain? There are anti-epileptic drugs (AEDs) that work to reduce the intensity of pain signals going to the brain, such as Lyrica, Neurontin, Zonegran (zonisamide), and Topamax. Although Lyrica gets the most publicity, it is expensive and may also cause weight gain. What about the other AEDs that are available as less costly generics?
“In terms of effective pain modulation,” says Bateman, “I would list Lyrica and Neurontin well ahead of the others. Although a clinically important group of patients do gain weight on Lyrica, I find that the majority of patients don’t. However, I do counsel all patients at the onset to avoid dietary sugar and fat, and to not ‘give in’ to the increased appetite.
“Many other AEDs modulate pain somewhat and can be effective tools,” says Bateman. “I use Topamax and Zonegran in some patients because they aid in weight loss, and are much less likely to cause brain fog. Zonegran is a sulfa-drug relative, so patients must be screened for sulfa allergy. I start with 25 mg, then 50 mg, and have the patient slowly build up to 100 mg twice daily. Topamax may be a good choice for FM with migraines.”
Although Lyrica was approved by the U.S. Food and Drug Administration to treat FM pain, the clinical trials also showed a significant improvement in sleep. This is another reason for doctors to prescribe Lyrica and other AEDs with similar properties.
While Lyrica and other AEDs work on incoming pain processing problems in FM, there are also antidepressant medications that help the faulty pain inhibitory system work better, such as Cymbalta (duloxetine) and Savella (milnacipran). Tricyclics fall into this latter group (e.g., amitriptyline and cyclobenzaprine), but they may produce many more undesirable side effects. However, if cost is an issue, a small dose of one of these medications taken at night may help with pain and sleep.
Bateman says the clinical trials on Cymbalta show the drug takes effect within about a week. The change in pain is not huge, but it can be used for the central pain of FM. Savella may be even more effective overall, but Bateman says doctors have to work with their patients so they slowly adapt to the side effects. Obviously, one should get better pain relief by combining a drug that reduces the pain signals to the brain (e.g., AEDs) with one that boosts the effectiveness of the pain inhibitory system (e.g., anti-depressants). Although there are no studies to show that this is the way to go, Bateman says that clinically, many doctors are using this method.
“It’s good to remember that anything that helps reduce mood or anxiety symptoms, or that aids with sleep, may also help pain indirectly,” says Bateman. “I like Lamictal (lamotrigine) as a mood stabilizer and mild antidepressant, but I don’t find it does much for pain.” Lamictal is available as a generic and does not have the potential to interfere with sleep like antidepressants that modulate serotonin and/or norepinephrine.
“We use a lot of medications to modulate the symptoms of FM/CFS,” says Bateman. “You want to be frugal and pick the drugs carefully.” Bateman also strongly endorses non-drug therapies because they can be effective and enable patients to reduce their doses of medications.
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