Questions for Your Doctor: Fibromyalgia

One day you have aching muscles, tender skin, fatigue, headaches, flulike symptoms and difficulties concentrating. The next day you feel great.

That’s one reason coping with fibromyalgia symptoms is such a challenge.

But a doctor-approved treatment plan — which may include exercise, psychotherapy, medication and natural remedies — can help.

Here are 15 important questions to ask about your symptoms of  fibromyalgia and treatment:

1. Could there be another cause for my symptoms?
Before making a fibromyalgia diagnosis, doctors typically rule out other conditions that cause similar symptoms, such as thyroid disease, arthritis, lupus, infections and some medications (like those used to treat high cholesterol).

Unfortunately, there’s no objective measure — like an X-ray or a blood test — to decisively diagnose fibromyalgia.

2. What’s my long-term outlook?
Early diagnosis of the symptoms of fibromyalgia and treatment is the key to successfully managing symptoms of fibromyalgia, says Leslie Crofford, M.D., chief of rheumatology and director of the Center for the Advancement of Women’s Health at the University of Kentucky in Lexington.

“If you catch it early and develop a good self-management strategy, the condition doesn’t have to dominate your life,” she says.

3. What’s the first-line treatment for symptoms of fibromyalgia?
Your doctor may prescribe one of the following medications, which treat fibromyalgia in two different ways:

• Duloxetine (Cymbalta) and milnacipran (Savella) increase the amount of two neurotransmitters, serotonin and norepinephrine, in the brain. This reduces your sensitivity to pain.
• Pregabalin (Lyrica) blocks overactivity of nerve cells, which also reduces pain.

About half of those who try these drugs see modest improvement, Dr. Crofford says. Some patients respond better to medication than others.

“There may be other pathways involved in pain for which neither of these medications work well,” she says.

4. If these medications don’t help, what’s the next step?

IV Ketamine Infusion therapy has been shown to be very effective in treating Fibromyalgia

Your doctor may prescribe older medications “off-label.”

Although the Food and Drug Administration (FDA) hasn’t approved them for fibromyalgia, it allows physicians to prescribe such drugs to treat the condition.

These include amitriptyline (Elavil), cyclobenzaprine (Flexeril) and venlafaxine (Effexor), which increase neurotransmitters in the brain.

Also, antidepressants that affect only one neurotransmitter — such as fluoxetine (Prozac), paroxetine (Paxil) and sertraline (Zoloft) — are sometimes prescribed.

Another older drug, gabapentin (Neurontin), blocks overactivity of nerve cells.

5. Since many drugs used to treat fibromyalgia are antidepressants, is the disease psychological?
No. With fibromyalgia, the cause is a chemical change in the way the central nervous system (the brain and spinal cord) responds to pain, says Daniel Clauw, M.D., a rheumatology professor at the University of Michigan in Ann Arbor.

6. How do antidepressants ease my symptoms of fibromyalgia?
Some antidepressants have other effects too, Dr. Crofford says. The neurotransmitters they increase — serotonin and norepinephrine — also influence the way the brain responds to pain.

7. Are there medications to avoid?
People with fibromyalgia shouldn’t take opioids, including prescription pain medicines, such as Vicodin (acetaminophen and hydrocodone) and Oxycontin (oxycodone), she says.

“These medications actually contribute to the persistence of chronic pain,” she says. “They change the way your brain and spinal cord processes pain. When you stop them, there’s a rebound effect.”

This means your symptoms may actually worsen after you stop taking the drugs.

8. Will I need to make lifestyle changes?
Yes. Patients with the best results combine drug and non-drug therapies, Dr. Clauw says.

“You can’t just rely on pills,” Dr. Crofford adds.

For example, exercise is as important as medication. Inactivity disrupts the body’s natural rhythms and causes sleep problems, says Crofford. It actually leads to fatigue as well as deconditioning (muscle weakness), making daily activities more likely to cause injury and pain.

Overall, “staying in bed is one of the worst things you can do,” she says.

9. How can I exercise when it’s so hard to get up and move?
If your symptoms make exercise difficult, start off slowly, Dr. Crofford advises. Then begin to build endurance.

Find an activity you can do year-round.

If you’ve been inactive for a while, it can be as simple as taking the stairs instead of an elevator, Dr. Clauw says.

“If you haven’t had success in the past, try warm-water aerobics,” he suggests. This puts less stress on muscles and joints.

10. Is it possible to do too much?
Yes. Learn to pace your activities so you don’t overdo it on days you feel well, Dr. Crofford says. You’ll figure that out through trial and error.

11. How can I minimize a flare-up?
Think about what could have caused it. What was I doing the day before? Did I do too much? Or did I not move enough? Did something stressful happen?

Once you begin to see a pattern, avoid situations that cause you discomfort.But try not to dwell on it.

“With fibromyalgia, you may feel widespread pain followed by no symptoms at all,” Dr. Crofford says.

Focusing on symptoms always increases their severity.

Brooding about your condition can lead to depression too, she adds.

12. Other than exercise and medication, what else can reduce pain?
Don’t smoke. Exercise, get enough sleep, and eat a nutritious diet (including plenty of whole grains, fruits and vegetables).

These will keep your body strong and help you cope when symptoms of fibromyalgia flare, she advises.

Also, cognitive behavioral therapy (CBT) can teach you strategies to improve sleep, reduce stress and pace activities.

For basic, do-it-yourself CBT techniques, visit the Fibromyalgia Network website.

13. Will alternative therapies, such as massage, acupuncture, tai chi or yoga, help?
Some randomized trials show that yoga and tai chi help, Dr. Crofford says.

A 2010 study published in the New England Journal of Medicine studied 66 people with symptoms of fibromyalgia.

Half did stretching exercise, and the others practiced tai chi, which includes slow breathing, exercise and meditation — components thought to have physical, social and psychological effects.

The tai chi group showed significant improvement in their symptoms as well as sleep quality, mood and quality of life.

Although there’s no scientific evidence to back up other therapies like massage and acupuncture, some fibromyalgia sufferers claim they provide relief.

But you may actually have to try them before deciding if they work for you, Dr. Crofford adds.

14. What about supplements?
According to the National Center for Complementary and Alternative Medicine (NCCAM) it’s possible that low magnesium levels play a role in fibromyalgia, but there’s no conclusive evidence and more research is needed, Dr. Clauw says.

Still, he recommends magnesium to his patients because “it helps with the constipation associated with many fibromyalgia medications.”

15. How can I explain my disorder to friends and family?
“Bring your family to a doctor’s appointment,” Dr. Clauw says.

“The more educated they are, the better they can advocate for you.”

Symptoms of fibromyalgia are generally invisible to others, so “don’t get too caught up in trying to prove to people that you’re sick,” he advises.

Make sure family members are informed and supportive.

It will help when you need coaching.

“A fibromyalgia patient in the midst of a flare doesn’t want to exercise,” he says.

That’s when you need “gentle, nonjudgmental persuasion to get out of bed and go for a walk.”

By Ellen Wlody