FFinalistSouthampton · 2027
Musculoskeletal
AKT · Musculoskeletal/Vasculitis, PMR & GCAlow yield

Fibromyalgia

Chronic central pain-amplification syndrome (no inflammation or structural damage)

Overview

A chronic widespread pain syndrome driven by central sensitisation/abnormal pain processing, without inflammation or structural damage. It presents with diffuse pain, profound fatigue, unrefreshing sleep and cognitive 'fog', with normal investigations. It is a positive clinical diagnosis (not one of exclusion alone), and management is non-pharmacological first — exercise, education and psychological therapy.

Recognise

  • Chronic widespread pain (>3 months) with multiple tender points; profound fatigue and unrefreshing sleep
  • Cognitive disturbance ('fibro-fog'), headaches, IBS, low mood/anxiety, paraesthesiae
  • Examination and ALL investigations are normal (no synovitis, normal inflammatory markers/CK)

Red flags

  • Red-flag features (weight loss, fever, focal neurology, true weakness, abnormal bloods) → investigate for an alternative diagnosis
  • Do not over-investigate once the positive pattern is recognised — but don't miss a coexisting inflammatory/endocrine disease

Differentials & how to tell them apart

Polymyalgia rheumatica / inflammatory arthritisraised inflammatory markers, true stiffness/synovitis
Hypothyroidism / vitamin D deficiencyabnormal TFTs/vitamin D — correctable
Chronic fatigue syndrome / ME / depressionoverlapping; CFS/ME is defined by ≥3 months of disabling fatigue with characteristic POST-EXERTIONAL MALAISE (graded exercise no longer recommended); mood-predominant in depression

Investigations

Clinical diagnosis; investigations are done to EXCLUDE mimics and are normal — FBC, ESR/CRP, CK, TFTs, calcium, vitamin D; widespread pain index/symptom severity supports the diagnosis.

Management

Education + graded exercise + CBT; low-dose amitriptyline/duloxetine for symptoms

  1. 1Make a positive clinical diagnosis of widespread pain with normal investigations (done to exclude mimics). First-line management is non-pharmacological: education, graded aerobic exercise and CBT.Gate: Avoid opioids and NSAIDs (ineffective and harmful here); red-flag features or abnormal bloods → investigate for an alternative or coexisting diagnosis.
  2. 2Add low-dose amitriptyline, duloxetine or pregabalin for persistent pain/sleep disturbance; multidisciplinary self-management and pacing.
Education + graded aerobic exercise — first-line and most effective; the cornerstone of management
Psychological therapy (CBT) — for pain coping and associated mood/sleep problems
Low-dose amitriptyline or duloxetine/pregabalin — for pain/sleep if needed — modest benefit; avoid opioids and NSAIDs (ineffective here)
Sleep hygiene, pacing, multidisciplinary support — holistic self-management

Key points

Chronic widespread pain + fatigue + unrefreshing sleep + 'fibro-fog' with NORMAL investigations = fibromyalgia → exercise + CBT + education first; low-dose amitriptyline/duloxetine if needed. Avoid opioids/NSAIDs. A positive diagnosis, but don't miss a treatable mimic (thyroid, vitamin D).

Monitor & prognosis

Function, mood, sleep; response to exercise/CBT.

Chronic but improvable with self-management; no joint damage occurs.

Source: NICE chronic primary pain (NG193); EULAR fibromyalgia