Ways to treat fibromyalgia

How to Treat Fibromyalgia

FM pain can be minor or serious enough to interfere with daily activities. Thankfully, treatment can help manage pain.

1. Pain relievers

Medication is an option to reduce FM pain. Your doctor may recommend over-the-counter (OTC) pain relievers such as aspirin, ibuprofen, and naproxen sodium. These medications can help:

  • reduce inflammation
  • minimize muscular aches
  • improve sleep quality

Shop online for naproxen sodium.

2. Antidepressants

These can help ease pain and fatigue. Discuss the possible side effects of using antidepressants for FM with your doctor. For some people, antidepressants can cause a variety of unpleasant side effects such as nausea, weight gain, and loss of sexual desire.

3. Anticonvulsants

These seizure medications may also help reduce pain. The U.S. Food and Drug Administration approved pregabalin (Lyrica), the first anti-seizure drug for FM treatment. Gabapentin, which reduces nerve pain, may be suggested. But these medications come with possible side effects including:

  • dizziness
  • weight gain
  • swelling
  • dry mouth

4. Yoga

Research has shown that people with FM who participated in yoga classes experienced improved mood and less pain and fatigue. The classes included:

  • gentle poses
  • meditation
  • breathing exercises
  • group discussions

Try taking a yoga class. The practice increases muscle strength, incorporates meditation, and teaches different relaxation techniques. Just be sure to let the instructor know about your condition, so they can adjust the poses as needed for you.

Shop online for yoga mats.

5. Acupuncture

You may want to try acupuncture for pain relief. It involves pricking the skin with needles to:

  • promote natural self-healing
  • encourage a change in blood flow
  • change the levels of neurotransmitters in your brain
  • treat a variety of health conditions like chronic pain

A study in the Journal of Rehabilitative Medicine found that people with FM who received acupuncture benefited from pain relief for at least two years, compared to those who didn’t. For those who cannot tolerate the needles, acupressure may be an option.

The risks of acupuncture include soreness, minor bleeding, and bruising after treatment. Always make sure your acupuncturist is licensed to decrease risk of infection from unsterilized needles.

6. Physical therapy

Physical therapy techniques aim to improve your range of motion and strengthen the muscles. This can also help reduce FM pain. Your therapist will tailor a program to help manage specific symptoms. They can also teach self-care techniques, including FM education, to help you manage the fatigue and pain on your own. Research shows that pain management education can lead to increased performance during exercise.

Roland Staud, University of Florida, Gainesville, US, likens the current understanding of fibromyalgia to the traditional Indian story of seven blind mice trying to determine the identity of an elephant. One blind mouse feels a leg and calls it a pillar; another grabs ahold of the tail and reports finding a rope. Not until all the parts are considered as a whole does a complete picture of the beast emerge.

Likewise, rheumatologists with patients complaining of muscle aches may diagnose fibromyalgia, whereas a gastroenterologist proclaims IBS the cause of pain, but apart from complaints of regional pain in IBS, the overall symptoms of these two conditions look remarkably similar. Patients with low back pain, osteoarthritis, and other common chronic pain conditions can also develop this characteristic set of symptoms.

Today, researchers are sketching out a picture of fibromyalgia as a pain disorder that can be triggered by any number of individual maladies, each one heightening future risk for developing this enigmatic condition.

Brain pain?
Researchers and doctors have traditionally classified different types of pain into several categories. Nociceptive pain is the acute protective signal of impending tissue damage that arises from stepping on a tack, for example. Inflammatory pain results from the activity of immune cells, as in osteoarthritis. And neuropathic pain springs from nerve damage that results from diabetes or chemotherapy, for instance. Fibromyalgia has been a conundrum in part because it doesn’t really fit into any of those categories, though some symptoms resemble inflammatory pain, and others neuropathic pain.

Over the years, researchers have tried to craft a new category to contain fibromyalgia, which they have variously called functional, dysfunctional, or somatoform disorders. “The term that we prefer is ‘centralized pain,’ meaning that pain clearly is coming largely from the brain rather than from out in the periphery,” says rheumatologist Daniel Clauw, University of Michigan, Ann Arbor, US.

Because the pain of fibromyalgia seems to originate from the muscles, for years rheumatologists studied patients’ muscle and joint tissues, but found no evidence of inflammation or damage that could cause pain. Without evidence for bodily injury underlying the pain, many researchers turned to studying the brains of people with fibromyalgia. Some, including Clauw, have embraced the idea that fibromyalgia is primarily a disease of the brain.

The unifying symptoms, like widespread pain and fatigue, of fibromyalgia and other such syndromes indicate that changes in the central nervous system are at play, Clauw says. Brain imaging studies have indeed shown evidence of structural and functional changes in the brains of patients with fibromyalgia. And anti-depressant and anti-seizure medications that are effective for some people with fibromyalgia work in the brain, he adds.

But other researchers contend that all chronic pain conditions lead to changes in the brain, and in fact every experience of pain—whatever its initial cause—emerges from the brain. Many researchers in the field therefore are still searching for as-yet-undetected pathological processes in the body that may be driving the symptoms of fibromyalgia—processes that might be reversible.

Evidence of peripheral nerve damage
In 2013, several groups published evidence of neuropathy, or damage and dysfunction, in the small nerve fibers that transmit pain signals from the skin, in patients diagnosed with fibromyalgia. One study led by Claudia Sommer, University of Würzburg, Germany, found dysfunctional nerve activity in twenty-five adults with fibromyalgia, according to sensory testing (in which subjects reported when they detected hot or cold stimuli) and electrical recordings of peripheral nerve activity. In addition, skin biopsies from fibromyalgia patients often revealed withered or sparse nerve endings. These abnormalities were not present in healthy control subjects or in ten subjects without pain but with depression, a condition that shares some aspects of fibromyalgia such as fatigue and inactivity.

Another study, led by Anne Louise Oaklander at Massachusetts General Hospital, Boston, US (see related RELIEF podcast with Oaklander here) also used skin biopsies, with similar findings. Oaklander found that forty-one percent among 27 adult subjects meeting diagnostic criteria for fibromyalgia also met the diagnostic criteria for small-fiber polyneuropathy (SFPN), a common neuropathic pain condition with myriad causes, whereas only three percent of healthy control subjects showed signs of SFPN.

A third study, led by Jordi Serra, MC Mutual, Barcelona, Spain, and Neuroscience Technologies, London, UK, measured dysfunctional nerve activity in the peripheral nerves of fibromyalgia patients and showed that it mimicked nerve activity seen in patients with SFPN but not healthy controls. Serra uses a highly specialized technique called microneurography to record activity from individual nerves in a person’s skin.

Together, these reports suggest that, somehow, damage to or dysfunction of peripheral nerves is a contributing factor in many cases of what has been diagnosed as fibromyalgia. But many questions remain about the link between neuropathy and fibromyalgia.

Oaklander stresses that it’s important to identify any potential underlying medical causes of fibromyalgia, because some can be halted or improved. Most cases of SFPN can be traced to potentially treatable conditions including diabetes, chemotherapy for cancer, an autoimmune reaction, or—rarely—a genetic abnormality; some cases of SFPN remain mysterious in origin. Oaklander says that many of her patients with neuropathies have improved with treatment of these underlying conditions rather than relying on a standard course of treatment with painkillers. Certainly not all cases of fibromyalgia are rooted in undiagnosed SFPN, Oaklander says, “but pulling out the 40 percent who appear to have SFPN may help researchers to find the cause in the remaining 60 percent as well.”

But for patients, a diagnosis—or even treatment—of SFPN may not be sufficient to halt fibromyalgia. Kathleen Sluka, University of Iowa, Iowa City, US, says that while the findings of peripheral neuropathy in fibromyalgia patients are an important piece of the puzzle, “patients need to understand this is not going to lead to a miracle cure. There are multiple mechanisms underlying fibromyalgia, and there may be several going on at once. Treatments need to be aimed at each of those components and tailored to the individual,” she explained.

Is it a real thing?
While fibromyalgia has gained recognition in recent years as a condition with biological underpinnings, many doctors practicing today still doubt that fibromyalgia is real, or they refer to it as a psychological disorder—one that’s “all in the head.” But, like many diseases in the history of humankind, Serra says, fibromyalgia is evolving in our cultural consciousness. For example, 200 years ago, people with epilepsy were regarded as crazy, or possessed by the devil. Only when electroencephalography (EEG) came along—a test that records brain activity using electrodes attached to the scalp—did doctors realize that the disease was rooted in abnormal brain activity.

“Now, no one doubts that epilepsy is a neurological condition that can be treated. But back then, it was impossible to convince doctors it was a real disease. Fibromyalgia is very similar, in that we have patients who complain of pain and other mysterious symptoms and are studied by physicians who find nothing wrong,” so they often dismiss or ignore the patients, Serra says.

That dismissal can make patients feel crazy, even though they know their pain is very real. “One of the most frustrating things for patients is that they are often not believed—and this may be constant, going on for years,” Serra says. While the new findings of peripheral nerve damage in fibromyalgia patients may not offer a cure or even an immediate treatment, they represent the first objective, physical evidence of dysfunction linked to their illness. “The skin biopsies and microneurography are objective tests. To have a doctor say your nerve activity is abnormal, or that you have small-fiber neuropathy” can be a source of tremendous relief and validation for patients, Serra says.

It’s entirely possible that, until now, studies have missed signs of damage or dysfunction in nerves, Serra says, because they were undetectable with the relatively blunt diagnostic tests used in the past. Peripheral nerves, Serra says, are incredibly sensitive to slight changes in their surroundings, which can alter their activity. “The excitability of nerves is very fine-tuned,” he emphasizes. For example, a pain nerve fiber might be spontaneously active, but once the patient relaxes, that activity stops. That might happen because the patient’s breathing slows, perhaps changing the acidity of blood, or some other factor in the nerve fiber’s environment. “Just this little change in balance determines whether the nerve is firing or not firing,” Serra says. This finding, he explains, also fits with the relationship between stress and pain. “We know this—all patients say, ‘when I’m stressed, I’m worse, and when I’m relaxed, I feel better.’”

Stress and trauma have long been known as contributing factors in fibromyalgia, but researchers are still struggling to find out how they increase risk. “We know that psychology is strongly associated with chronic pain,” Staud says. “Emotional trauma is one of the vulnerabilities for the pain modulatory system, and families with emotional disorders are at much higher risk for chronic pain than others.” Genetic differences—in genes associated with pain or stress, for example—may explain some of that risk, but traumatic experiences seem to accelerate development of fibromyalgia, even in the absence of physical injury.

“Clearly any kind of stress or trauma can bring it on, whether it’s physical, emotional or even a stress on the immune system,” Clauw says. “That includes everything from early-life trauma to a major auto accident to the psychological stress of being deployed to war. Stress is so important.” Today, researchers are actively investigating what types of substances might circulate in the blood or affect the brain to link stress with fibromyalgia. The top contenders include stress hormones and inflammatory molecules released by immune cells in the brain or body.

End of the line?
Many researchers agree that what is now called fibromyalgia—characterized by widespread pain, fatigue, and cognitive and emotional disturbances—may be the final station on the chronic pain track. “Fibromyalgia is the endpoint—the end of the continuum,” says Clauw. “And maybe we can prevent people from getting there if we identify their risk early and treat aggressively,” which might include anti-depressant medications shown to improve fibromyalgia pain in some patients, he says.

Staud went further, saying that everyone might be at risk for chronic pain. “It’s not just the end of the line for chronic pain patients; it’s the end of the line for all of us.” How quickly we get there, he says, depends on how well we can fend off risks. “If you avoid significant trauma in life, be it physical or emotional, that can help keep your pain modulatory system very active and competent.” Otherwise, he says, “you get closer to chronic pain.” Of course not everyone develops chronic pain; some people seem to be protected for life. “For some, it’s a very flat trajectory toward that endpoint; for others, it’s very steep.”

How can people build up this protection to stave off chronic pain? Staud says there are four concrete steps to take in order to minimize risk, whether an individual already has chronic pain or not. First, prevention of injuries or other traumatic events that can lead to pain is important. Of course, this is not always possible, but for someone with fibromyalgia, it might mean avoiding stressful situations that could trigger a pain episode. Second, Staud says, physical exercise seems to condition the body against pain. Third, sleep is also protective, so getting as much high-quality sleep as possible will help. Finally, psychological coping skills are protective against pain. “The ability to adapt to stress of all sorts is critical,” Staud says. Cognitive-behavioral therapy (CBT), mindfulness, and supportive social interactions can all help build this resilience. However, Staud says, “there is a relatively small group of people who practice these steps consistently and effectively. The majority of the population does not.”

Staud stresses that all of these recommendations require tremendous effort on the part of the patient—effort they might not be able to expend. Telling people with fibromyalgia to exercise, sleep more and get therapy, he says, “is similar to telling poor people to save more money and be frugal in order to get rich.” Staud says the emphasis in pain care should instead be on prevention and early recognition, and then on building financial, social and emotional support for patients.

But, for those who are able to exercise, Sluka says the research shows that physical activity is perhaps the single most effective approach to alleviate chronic pain. “In the scientific literature, there is strong support for exercise as a way to mitigate pain—it’s one of the most effective treatments,” but only recently are doctors coming around to the idea of “prescribing” exercise for pain. Inactivity, she says, which is common in fibromyalgia patients, might contribute to or even cause some symptoms of fibromyalgia. “Research shows that higher physical activity leads to greater pain inhibition, it can improve cutaneous nerve innervation , and it can alter the immune system. Exercise does wonderful things.”

Sluka also says it is important that patients play an active role in setting the course for their treatment, though this does place an additional encumbrance on patients already bearing the burden of chronic pain. “Patients need to take control and help manage their own condition,” Sluka says. That’s for two reasons: first, because things like improving sleep and getting exercise, which are under a patient’s control, may lessen pain and improve function. And second, by gaining a sense of control, patients can reduce their stress and pain.

Finding a doctor who recognizes fibromyalgia and is willing to try different approaches is also crucial. Some people suffer from fibromyalgia for years, seeing only doctors who tell them there’s nothing wrong with them, or they undergo surgery that doesn’t help, and they become discouraged. “For a lot of people, this is a long struggle. They end up beaten down, feeling helpless and hopeless,” Clauw says. When Clauw encounters these patients, he says it’s very difficult to help them. “We have to attempt to prop them up and reinvigorate them. Patients have to embrace the fact that there are things they have to do to get better. We can’t give them a drug to cure this—we can’t do that with any pain condition. The goal is to get pain appropriately diagnosed and treated early on, so they don’t get to that end of the pathway.”

“The notion that there’s nothing we can do for people with fibromyalgia is really just wrong,” Clauw says. “When you look at everything available, there is almost always something that will help.” It’s important to try different medications and nondrug therapies, he says, because which treatments may work will vary from person to person.

Although many questions about the causes and treatment of fibromyalgia remain unanswered, Serra says, “it’s a very exciting moment in pain research. We’re beginning to see things we couldn’t even imagine. We will begin to make sense of this disease soon.”

Stephani Sutherland, PhD, is a neuroscientist, yogi, and freelance journalist in Southern California. Find her at StephaniSutherland.com or on Twitter @SutherlandPhD

Additional Reading:

Fibromyalgia: Maligned, Misunderstood, and (Finally) Treatable by Bret Stetka, Scientific American

Nerve Damage Might Explain Chronic Pain by Stephani Sutherland, Scientific American Mind

Related RELIEF content:

Is There a New Explanation for Fibromyalgia? A Podcast with Anne Louise Oaklander

Related Pain Research Forum content:

Multiple Studies, One Conclusion: Some Fibromyalgia Patients Show Peripheral Nerve Pathologies

Elucidating the Pathophysiology of Peripheral Neuropathies: A Conversation With Claudia Sommer

Fibromyalgia

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What Is Fibromyalgia?

Fibromyalgia is a chronic condition characterized by a generalized, aching pain. In the United States, an estimated five million people suffer from this disorder. Most are women of childbearing age.

The Symptoms Of Fibromyalgia

Fibromyalgia symptoms include aches and stiffness in muscles, tendons (which attach muscles to bone) and ligaments (which attach bones to each other). The pain can occur in any part of the body and can be widespread or localized. Fibromyalgia symptoms typically develop gradually and frequently come and go in cycles. Women tend to experience more widespread problems, while men more often develop localized fibromylagia symptoms, such as pain in the shoulder.

  • Pain. Fibromyalgia pain is often described as a deep muscular aching that is either burning, throbbing or sharp. The pain and stiffness is often worse in the morning.
  • Fatigue. The sensation of being drained of energy and unable to concentrate can vary from mild to incapacitating.
  • Difficulty sleeping. Sleep does not feel refreshing; and fibromyalgia patients report feeling exhausted when they wake up.
  • Sensitivities. About 50 percent of fibromyalgia patients report sensitivities to noise, bright lights, odors, medications and certain foods.
  • Chronic headaches. An estimated 50 percent of patients report migraines or tension headaches.
  • Irritable Bowel Syndrome. Between 40 to 70 percent of patients experience diarrhea, constipation, and abdominal pain and gas.

Other fibromyalgia symptoms may include dizziness or lightheadedness, menstrual cramping, jaw pain, numbness and tingling sensations, cognitive and memory problems (often called “fibro fog”), temporomandibular joint disorder, pelvic pain, restless leg syndrome, sensitivity to chemicals and temperature, and anxiety and depression. These symptoms can vary in intensity and, like the pain of fibromyalgia, wax and wane over time.

Because none of the symptoms of fibromyalgia are unique to this condition, physicians cannot make a diagnosis based on the presence of one or more of them. Instead, today’s diagnostic criteria specify that patients must have had pain in four quadrants of the body for a minimum of three months and tenderness in at least 11 of 18 specific areas called “tender points” on the neck, shoulders, back, hips, arms or legs that hurt when touched.

The Causes Of Fibromyalgia

New research suggests that imbalances in the nervous system amplify normal sensation, making even a slight touch feel painful. This super-sensitivity to pain appears to be genetic. Fibromyalgia does run in families, and researchers have identified one gene believed to be involved in the syndrome. Patients also have higher-than-normal levels of a neuropeptide called substance P that is involved in the communication of pain signals to the brain, and lower-than-normal levels of the pain-mitigating hormones serotonin and norepinephrine.

Even if you are born with a genetic predisposition to fibromyalgia, you still need to experience something that triggers the disorder. This can be a viral infection, emotional stress, an accident or injury or, perhaps, exposure to certain drugs or chemicals.

What Is The Conventional Fibromyalgia Treatment?

There is no single reliable fibromyalgia treatment. It often requires a team approach, enlisting physicians who are familiar with the disorder (not all doctors are; in fact, some physicians argue that fibromyalgia isn’t real since no physical signs can be detected by x-rays, blood tests or other diagnostic techniques).

Only a single pharmaceutical drug, pregabalin (Lyrica) has been approved by the FDA as a fibromyalgia treatment, but a number of other drugs are frequently used:

  • Painkillers: These can range from familiar over-the-counter drugs such as acetaminophen (Tylenol) to prescription medicines, sometimes including narcotics, for those with severe muscle pain. However, no solid evidence has shown that narcotics are effective for the chronic pain of fibromyalgia and continued use presents a risk of physical or psychological dependence.
  • Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): This category includes aspirin, ibuprofen (Advil, Motrin), and naproxen sodium (Anaprox, Aleve). These drugs work by inhibiting prostaglandins, substance which play a role in pain and inflammation. They can help relieve the muscle aches of fibromyalgia as well as the menstrual cramps and headaches often associated with the disorder.
  • Antidepressants: These drugs help elevate levels of serotonin and norepinephrine in the central nervous system. Low levels of these chemicals are associated not only with depression, but with pain and fatigue. Tricyclic antidepressants taken at bedtime in dosages lower than those used to treat depression can help promote restorative sleep, relax painful muscles and heighten the effects of endorphins, the body’s natural pain-killers. Other antidepressants, selective serotonin reuptake inhibitors (SSRIs), taken in doses lower than those used to treat depression, can reduce fatigue and some other symptoms associated with fibromyalgia. A combination of the tricyclic, amitriptyline, and the SSRI fluoxetine seems to relieve symptoms better than either drug alone.
  • Benzodiazepines: Such as valium may be prescribed to help relax tense, painful muscles and stabilize the erratic brain waves that can interfere with deep sleep. These drugs can also relieve symptoms of restless legs syndrome, which is common among people with fibromyalgia. Because of the potential for addiction, doctors usually prescribe benzodiazepines only when other drugs haven’t helped.

In addition, fibromyalgia treatment may include a combination of physical and occupational therapy, as well as instruction in pain-management and coping techniques, and in properly balancing rest and activity.

What Natural Treatments Does Dr. Weil Recommend For Fibromyalgia?

The following lifestyle changes:

  • Exercise. Regular exercise has proven one of the best treatments. Although muscle pain may worsen during exercise, the pain usually dissipates within 30 minutes. Stretching and low-impact aerobic activity (swimming, walking, yoga, or using cardiovascular machines like stationary bikes or elliptical trainers) are often the most effective.
  • Regular sleeping habits. This is critical for reducing pain and improving energy and mood.
  • Relaxation techniques. Meditation, yoga or breath work can help counteract stress.
  • Cognitive-behavioral therapy. To learn how to cope better with symptoms and stress.
  • Acupuncture or massage. Both are often helpful in relief of whole-body systemic conditions.
  • The Feldenkrais Method. To correct poor posture or habits of movement that may contribute to pain.

Nutrition And Supplements For Fibromyalgia

  • A diet rich in organic fruits, vegetables, and whole grains can fortify your body’s natural defenses and healing system.
  • Eliminate polyunsaturated vegetable oils, margarine, vegetable shortening, all partially hydrogenated oils, and all foods (such as deep-fried foods) that might contain trans-fatty acids. Use extra-virgin olive oil as your principal fat.
  • Increase intake of omega-3 fatty acids.
  • Eat ginger and turmeric regularly for their anti-inflammatory effects.
  • In addition to a daily antioxidant regimen, take 250 mg of magnesium and 500-700 mg of calcium daily to help relax and maintain nerves and muscles. (However, Dr. Weil does not recommend calcium supplements for men.
  • Boswellia and malic acid may also be beneficial.

Foods to Avoid with Fibromyalgia

Sensitivity to pain is a well-known symptom of fibromyalgia. A lesser-known symptom is an enhanced sensitivity to various substances, including food.

See Characteristic Symptoms of Fibromyalgia

Following an anti-inflammatory diet and being aware of food sensitivities can help people with fibromyalgia get the most out of their food while avoiding symptom flare-ups.

See An Anti-Inflammatory Diet for Arthritis

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Foods Likely to Make Symptoms Worse

The following foods may worsen symptoms by increasing inflammation, aggravating food sensitivities, or both.

  • Sugar. Reducing or eliminating sugar can have a significant impact on health for two reasons. First, the medical literature has shown that eating foods high in sugar is linked to increased fibromyalgia pain.1 Second, limiting sugar helps control weight. Being overweight puts extra stress on the body, contributing to fatigue, and stored fat may lead to inflammation in some cases. Sugar is a well-known ingredient in candy and soft drinks, but is also in foods considered to be healthy—such as yogurt. When checking nutrition labels, it is helpful to know that glucose, fructose, and sucrose are other names for sugar.
  • See The Ins and Outs of an Anti-Inflammatory Diet

  • Carbohydrates. Refined carbohydrates such as cookies, many breads, pastries, and white rice are digested quickly, causing blood sugar levels to spike. The effect does not last, however, and blood sugar soon drops, making the individual hungry again. These fluctuations can make the fatigue and pain of fibromyalgia worse and contribute to overeating.2 When eating carbohydrates, whole wheat sources should be chosen. Whole wheat foods digest more slowly, avoiding the highs and lows that occur with other carbohydrates.

    See Celiac Disease and Low Thyroid vs. Fibromyalgia

    One small research study focused on women diagnosed with fibromyalgia who also had irritable bowel syndrome (IBS) and a food intolerance. (Many people with fibromyalgia also have irritable bowel syndrome.) When the women cut back on eating a specific group of carbohydrates, they reported a 50% reduction in irritable bowel symptoms and a 22% decrease in other symptoms, including pain. The restricted carbohydrates were a type not well absorbed in the small intestine. Such carbohydrates include lactose (an ingredient in milk and other dairy foods), fructose (in some fruits and vegetables, honey, and other sweeteners), and grains.3

  • Processed foods. Sugar and unhealthy fats, which increase inflammation, are a large part of many processed foods. Flavorings and preservatives commonly used in processed foods also may trigger food sensitivities.
  • See What Are Anti-Inflammatory Foods?

  • Unhealthy fats. Vegetable oils, such as corn oil, safflower oil, and peanut oil, have an inflammatory effect, especially when used to fry food. The medical literature has linked fried foods to worsening of fibromyalgia symptoms.1 Unhealthy oils are a common ingredient in many processed foods, such as cookies, doughnuts, and crackers. Pizza and cheese are also major sources of unhealthy fats.
  • Alcohol. While some research has found moderate alcohol use can ease symptoms,4 some people with fibromyalgia report alcohol causes symptoms to flare. Drinking alcohol while taking certain medications prescribed for fibromyalgia—such as anti-convulsants, antidepressants, and acetaminophen (an ingredient in many medications) could cause harmful interactions.

In This Article:

  • Food and Fibromyalgia: What to Know
  • Foods to Avoid with Fibromyalgia
  • How to Create a Fibromyalgia-Friendly Diet
  • Ingredients That May Trigger Fibromyalgia Symptoms

This is not a comprehensive list of foods that may trigger symptoms. Other foods and ingredients that may cause symptoms for some people include, but are not limited to:

  • Gluten
  • Red meat
  • Fruits and vegetables in the nightshade family, such as tomatoes, white potatoes, green peppers, and goji berries.
  • Dairy products
  • Eggs
  • Caffeine

See How Gluten Can Cause Joint Pain

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Learning About the Body’s Reaction to Certain Foods

If a food appears to trigger symptoms in an individual, eliminating the food entirely for several weeks is a good way to determine its impact. Keeping a detailed food log to track symptoms when the food is removed and added back may also be helpful.

Reducing sugar and sugary foods can have an additional benefit, helping the individual overcome a craving for sweets for the long term.

The doctor can be a good resource on food sensitivities and should be informed of problems encountered with different foods and ingredients. In some cases, the doctor may suggest testing for food sensitivities or allergies to narrow the list of potential problem foods.

See Doctors Who Treat Fibromyalgia

  • 1.Timmerman GM, Calfa NA, Stuifbergen AK. Correlates of body mass index in women with fibromyalgia. Orthop Nurs. 2013;32(2):113-9.
  • 2.Ernst A, Shelley-Tremblay J. Non-Ketogenic, Low Carbohydrate Diet Predicts Lower Affective Distress, Higher Energy Levels and Decreased Fibromyalgia Symptoms in Middle-Aged Females with Fibromyalgia Syndrome as Compared to the Western Pattern Diet. Journal of Musculoskeletal Pain. Volume 21, 2013, Issue 4. Page 365-370. dx.doi.org/10.3109/10582452.2013.852649.
  • 3.Maruma AP, Moreirab C, Saraivaa F, Tomas-Carusc P, Sousa-Guerreiroa C. A low fermentable oligo-di-mono saccharides and polyols (FODMAP) diet reduced pain and improved daily life in fibromyalgia patients. Scandinavian Journal of Pain. Volume 13, October 2016, Pages 166–172. dx.doi.org/10.1016/j.sjpain.2016.07.004.
  • 4.Kim CH, Vincent A, Clauw DJ, et al. Association between alcohol consumption and symptom severity and quality of life in patients with fibromyalgia. Arthritis Res Ther. 2013;15(2):R42.

Fibromyalgia Syndrome: A Case Report on Controlled Remission of Symptoms by a Dietary Strategy

The ineffectiveness of pharmacological therapies in FMS came to patient’s knowledge (1). The patient refused the proposed muscle relaxant drug (i.e., tizanidine) on the basis of its unproven effectiveness (1), and she also refused the proposed selective serotonin–norepinephrine re-uptake inhibitor (SNRI) (i.e., duloxetine) (12) on the basis of awareness of collateral effects (13) and development of pharmacological addiction. The patient generally feared collateral effects of the drug treatments, and she was rather interested in the novel metabolic approach for the symptomatic remission in FMS (11).

3. Therapeutic Protocol

3.1. Guidelines (11)

The therapeutic protocol is a strict diet. It was devised to facilitate Trp absorption, and thus guarantee its bioavailability as a substrate for 5-HT synthesis. In order to sustain 5-HT synthesis, it is mandatory to remove molecules that could negatively affect the fate of Trp in the gastrointestinal tract. The core of this approach is the exclusion of some carbohydrates from the diet and the proper intake of Trp with food (11). Because of fructose is a high reactive sugar (14), limiting the intake of fructose as much as possible is the essential point, including fructose chains, such as fructans and inulins, and some other molecules that do not have specific transport systems (e.g., sorbitol). Glutamate and aspartame should also be excluded (11).

3.2. Diet

The patient’s diet includes eggs, meat, fish, clams, potatoes, carrots, celery, spinaches, beets, chards, dark chocolates (at least 70 + % cacao), rice, millet, carob powder, walnuts, extra virgin oil, grape seed oil, thyme, sage, rosemary, coffee, green tea, and small amount of almonds. Almonds, despite containing fructose, still belong to the patient’s diet, as they are well tolerated in small amount, suggested to be consumed together with a glucose source, typically rice or potatoes to activate GLUT2 transporter as remarked in Ref. (11).

Any food, beverage, or herb not in the previous list and not according to treatment guidelines is excluded from the diet protocol. Particularly, processed food containing artificial sweeteners, high fructose corn syrup, sorbitol, glutamate, and aspartame must be excluded: among others soft drinks, fruit juices and the majority of confectionery (11). Food containing free fructose, such as honey and fruits, must be removed from patient’s diet. Most legumes, wheat and most cereals, and many vegetables that contain fructans and inulins (15) must also be removed (11). Attention must also be paid to the excipients in pharmacological preparations, pills, syrups, and solutions (16).

Compared with the previous patient’s diet, the one proposed here does not affect the total daily energy intake (2,200–2,400 kcal/day), but the nutritional profile concerning a reduction in carbohydrates, fibers, and an increase in protein and fat intake. The patient’s diet is thus composed of 31–36% carbohydrates, 30–32% fats, 25–27% proteins, and 9–10% fibers. The previous diet was mainly a Mediterranean diet. It was rich in vegetables, fresh fruits, dried fruit, cereals, and legumes. It contained a moderate amount of fish, meat, dairy products, eggs, nuts, and sweets. Its proportion of nutrients was: 55–56% carbohydrates, 30–32% fats, 17–18% proteins, and 16–18% fibers.

3.3. Therapeutic Approach

In order to assess her dietary intake, the patient was asked to keep a food diary. This method requires the subject to list the consumed food and the state of health, reporting the presence of symptoms: widespread pain, fatigue, morning stiffness, bowel function, headaches, sleep quality, cramps, prickling sensation at fingers and toes, mood changes, anxiety, and depressive mood among others. This method allows to evaluate compliance with the diet guidelines and the impact of diet modifications based on symptoms. It makes the patient an active subject to fight against the disease. This approach highly contributes to patient’s motivation and compliance with protocol as it makes the patient conscious of her power on the control of symptoms.

3.4. Patient Clinical Response

The growing severity of symptoms highly motivated the patient to strictly follow the diet guidelines. For a complete picture, the patient had already been on a lactose-free diet for 3 years and on a pork meat-free diet for 5 years.

Dietary modifications resulted in a rapid improvement of the patient’s condition after only a few days up to the full resolution of the majority of symptoms in few weeks. Symptoms of depression disappeared. Fatigue unrelieved when rest disappeared and she regained restorative sleep. Chronic musculoskeletal widespread pain and morning stiffness had a marked improvement up to no longer present. She recovered her energy and vitality. She got completely independent in all the activities of her daily life as before the onset of the disease by solving the occupational and social disabilities.

The patient broke the dietary protocol: not admitted foods were arbitrarily, deliberately, and voluntarily assumed (for instance, among others: eating a pear, or a fig, or an onion, or asparagus). It plays as negative control. It is significant for three different reasons: to exclude a major placebo component in the remission of symptoms, to evaluate the short-term effectiveness of the treatment, and to validate the protocol as a final cure or a remission protocol. The recurrence of symptoms is correlated with diet faults. The treatment leads to a remission but it is not a final cure.

Two months after the beginning of the diet the patient was vastly improved in every aspect. She regained her positive mental outlook. She returned to full employment. She recovered her energy and vitality as she did not since years.

3.5. Subsequent Course

12 months after the differential diagnosis and 10 months after the beginning of the diet modification the patient is still on diet. Marked not keeping occurred few times, being she well aware of the consequent recurrence of symptoms: when isolated, little faults trigger little symptoms; nevertheless, repeated and continuing faults have the potential for leading to the previous chronic condition of pain, fatigue, and mood symptoms. Moreover, being pain-free, the patient started physical aerobic exercise which she was unable to perform before due to stiffness and widespread musculoskeletal pain. Some comorbidities did not completely solve: sensitivity to cold, hypersensitivity to odors and noise, dysmenorrhea, and memory lapses are still present.

4. Discussion

4.1. FMS Burden

Fibromyalgia syndrome is really a challenging, insidious, and disabling disease that afflicts patients and their relatives as a real burden in everyday life (10). Epidemiological data clearly demonstrate the socio-economical burden associated with FMS and the urgency of effective answers (4, 10, 17–19). The diagnosis often delayed may exacerbate patient’s conditions. Being doubted due to the invisibility of pain is perceived as a “double burden.” Unfortunately, it is a common condition among patients (9).

Despite the large number of pharmacological and non-pharmacological clinical trials and studies performed, since nineties, an effective cure still lacks (1). The crucial role of 5-HT in FMS is no more a matter of debate. It has been clearly observed in experimental studies, although still not fully understood in its pathophysiological mechanism. Low levels of 5-HT and/or of its precursor Trp were variably observed in such studies, early during 1990s (20–22) and more recently (7, 23, 24). The introduction of selective serotonin re-uptake inhibitors (SSRIs) and SNRIs as a pharmacological therapy in FMS was the consequence in the clinical practice (3, 6, 25–29). Besides Trp, low levels of other essential aminoacids (30, 31) and altered aminoacid homeostasis (32) have been reported in patients with FMS as compared to the general population: anyway, these findings did not translate into an effective cure (1). Surprisingly, the “2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria” (33) did not contain any explicit reference to blood testing in this direction.

4.2. The Novel Remission Protocol Beyond the State of the Art

In this scenario, where the challenge for physicians and healthcare systems to face FMS is clear and still open (1), we report the first case of controlled remission in FMS following a novel metabolic approach (11). This report shows the crucial role of diet in FMS, and food choice as a key strategy for its management. The marked improvements of the patient’s clinical condition open great perspectives to face up FMS burden giving the patients an effective strategy. Intrinsically, a withdrawal approach avoids the potential side-effects associated with pharmacological therapies . The effectiveness-to-cost ratio of this approach is evident. It is a low risk and accessible therapeutic approach with virtually no costs for the treatment itself, than those related to possible vitamin and mineral salt supplements, and blood testing to evaluate their levels. The economic perspective could be relevant bearing in mind the significant number of patients.

Dietary modifications in FMS are not a new approach: different diets were attempted in the past, variably focused on the elimination of certain food or chemical additives (37). Nevertheless, the therapeutic approaches proposed till now often did not ground on a solid theory which is able to fully predict and explain the experimental outcomes.

4.3. The Possible Role of the Placebo and Nocebo Effects

As in any therapeutic approach implemented for chronic pain, a significant placebo response should be considered. The placebo effect is reported in FMS (38, 39). Breaking the diet protocol with not admitted food aims to exclude the remission of symptoms by a main placebo contribution. Although the placebo component could not be excluded at all a priori, the occurrence of an ad hoc nocebo effect precisely correlated with diet faults (i.e., voluntary breaks of protocol guidelines and accidental mistakes) is highly improbable.

4.4. Diet Management and Implementation in the Clinical Practice

It is already known that nonimmunologically mediated adverse reactions to food, which resolved following dietary elimination, are then reproduced by food challenge (40). Clinical improvement was reported after dietary treatment for fructose malabsorption in irritable bowel syndrome (IBS) patients by different studies (41, 42); particularly, a significant reduction of symptoms and improvements in the quality of life proportionate to the amount of eliminated fructose was reported by Choi et al. (43). The human capacity for fructose absorption is widely variable (44); incomplete fructose absorption can occur with doses as low as 5 g in individual considered as health subjects (45). Some authors report that patients with IBS associated with fructose malabsorption can tolerate 10–15 g of fructose per day (46). It is reasonable to suppose that a threshold exists in patients with FMS too, and that the tolerated amount of fructose and of the other not admitted molecules could be related to the severity of the patient’s conditions. The threshold can be very low: the patient reports that even very low amounts of free fructose are able to trigger the symptoms. In severe conditions, a compromise could not be possible at all, and a complete fructose-free diet is the suggestion. A patient-to-patient tailored approach is the best implementation in the clinical practice.

This report supports the protocol intrinsically effective for the remission of symptoms in FMS. It is a matter of fact that adherence to the protocol is correlated with symptomatic improvements and non-adherence with the recurrence of symptoms.

Because of the abundance of fructose in our food supply (as it is present not only in the form of simple monosaccharide, but also in the form of fructose chains), a strict fructose-free and fructan-free diet is binding, and maybe not required once patients experience sufficient relief from their symptoms. Particularly, in not severe conditions, a “re-introduction phase” could be approached by introducing into the diet small amounts of not admitted food, one at a time, in order to determine exactly how much fructose and the other not admitted molecules can be tolerated, to have the least restrictive diet, while keeping symptoms under control. This way, partial compliance with protocol guidelines may be a personal compromise to control the symptoms to a satisfactory level, while minimizing the social limitations that dietary restrictions impose.

The co-ingestion of glucose could be in principle beneficial to allow the presence of small amount of fructose in the diet (11). As previously mentioned, it activates the GLUT2 co-transporter, reducing the non-absorbed fructose (47, 48).

The difficulty of adhering to such restricted diet might be the criticism of it. Nevertheless, compliance with protocol guidelines demonstrates a high symptomatic improvement, being this way an incentive to be on diet. Diet modifications, that improved health condition in an IBS cohort of patients, reveal the willingness and the ability of patients to maintain dietary restrictions to avoid painful meal-related events (49). Patient’s dietary education contributes to the compliance with diet too, so that proper training and active involvement in the way to remission are crucial for successful and durable results.

5. Conclusion

This report shows a remarkable clinical improvement in FMS by a strict exclusion diet: remission of depression, pain, stiffness, chronic fatigue, and non-restorative sleep. This result opens new perspectives in the treatment of FMS solving the substantial functional limitations experienced by patients, virtually requiring no costs for the treatment itself. It could be an important point to be considered by healthcare systems, because of the incidence of FMS. The costs associated with the treatment are related to blood investigations and supplements of vitamins and mineral salts in case of deficiencies. Moreover, a dietary strategy has intrinsically no side-effects associated with pharmacological therapies.

A preliminary patient’s training should be considered, in order to gain proper knowledge of the protocol guidelines; it is important that patients can correlate the voluntary or chance failures to the recurrence of symptoms in order to avoid the gate of the “positive feedback loop.”

Because of its efficacy on symptoms, the absence of drug side-effects and its low cost, this approach could be an effective and accessible answer to the burden of FMS, at least to give patients a respite. A pilot study is required to ground this metabolic approach in FMS, and to finally evaluate its inclusion in the guidelines for clinical management.

Ethics Statement

The subject described in this report has given written informed consent for publication of the above-mentioned data on her FMS case.

Author Contributions

SML designed the report and wrote the final draft. FI followed the patient in her clinical history. SML and FI collected the patient’s clinical data and approved the final draft for publication.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

The authors thank Laura Bianchi and Giuseppe Zanotti for reading the draft of the manuscript and making useful suggestions to improve it. Associated editor Dr. Kayo Masuko followed the review process, since the beginning. Despite leaving the review process after the endorsement by reviewers, the authors wanted to track her presence in the manuscript history, as her requirements improved the final manuscript.

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