Signs and Symptoms

Chronic widespread pain, often associated with tender points, with symptoms lasting 3 months or more with no alternative explanation

• fatigue
• waking unrefreshed
• cognitive symptoms
• number of somatic symptoms

Differential Diagnoses

• there is wide DD for patients with aches, pains & fatigue
• Patients with other rheumatic disease, especially RA & SLE and often OA, may also have 'secondary' FMS

Please consider the following investigations to exclude other diagnoses, for example (but not limited to):

• Blood tests:
  • Full Blood Count (FBC)
  • Renal Function Test (RFT)
  • Liver Function Test (LFT)
  • Bone Profile
  • Thyroid Function Test (TFT)
  • C-reactive protein (CRP) or Plasma Viscosity (PV)
  • HbA1c
  • Creatine kinase (CK)

• Urine Dipstick (protein, blood and glucose)
• Additional tests - only if clinically indicated:
  • Haematinics (ferritin, B12, folate)
  • Vitamin D (if at risk of deficiency)
  • Coeliac screen
  • Serology (if risk of infection - consider: hepatitis, EBV, HIV, CMV)
  • Myeloma screen (if patient aged over 60yrs)
  • Cancer screening tests
  • Imaging
  • Autoimmune (Blood Tests for Rheumatology Conditions)
    • (N.B. In suspected cases of FMS there is no indication for auto antibody testing e.g. ANA. These tests should only be done when patient have specific CTD symptoms (e.g. Raynaud’s, sicca symptoms etc)

• Please see Investigations | Diagnosis | Chronic pain | CKS | NICE for further details.

Biopsychosocial and doctor-patient considerations:

• explain FMS is a disorder of pain processing, not damage or disease ('software, not hardware' for the IT literate)
• 'oversensitivity of the pain system' & 'volume dial in the pain relay centres has been wound up'
• Promote a good Dr-patient relationship & incorporate patient's ideas, concerns and expectations
• symptoms may worsen under times of psychosocial stress
• explain active management often improves quality of life
• Useful self help link for patients

Versus Arthritis - Fibromyalgia

Make a management plan

• Patient education
• Encourage self-management;
• Graded exercise;
• Prescribing options - 1st line low dose Tricyclic antidepressant e.g. Amitriptyline (Steroids / strong opioids not to be prescribed);
• Consider counselling for anxiety / depression.

Important practice points:

• Response rate to any medication is no more 1/3 improvement in under 50% of patients
• Medications are no better than an active exercise programme
• Strongly advise against prescribing strong opioids
• Regular review & stop if ineffective after a few weeks.
• Avoid polypharmacy
• Patients often end up on 5 medications, numerous adverse effects and pain scores of 10/10!

Referral Criteria

Please describe the expectations you have of the referral – many patients are disappointed with the outcome of the clinic appointment i.e. confirmation of diagnosis and advice re: activity & exercise. Specialists have no specialist interventions over and above what has been described.

Consider referral if:

• diagnostic uncertainty
• new symptoms suggestive of a rheumatological problem

NOTE:

• significantly uncontrolled FMS symptoms cannot be managed by a rheumatologist
• if severe symptoms and poor response to therapy
  • refer to either Pain Clinic (Consultant) if medication advice required
  • refer to the Pain Management Rehabilitation Team (for an MDT pain management approach)

Patient Information

Versus Arthritis - Fibromyalgia

Fibromyalgia Association

Fibro guide - self help-link

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: July 2016

Updated: January 2024