Fibromyalgia in the Emergency Department: Perspective

Fibromyalgia is a complex musculoskeletal pain disorder, which requires a delicate approach in the emergency setting. Above all else, it is imperative on every clinician to ensure these patients are not suffering from a life-threatening condition. Fibromyalgia is often characterized by diffuse musculoskeletal pains secondary to pain dysregulation and central sensitization and often accompanied by fatigue, sleep and mood disturbances, and/or cognitive dysfunction [1]. These symptoms often mimic other life-threats, and need to be carefully evaluated. Often, trauma does not precede an Emergency Department (ED) visit in patients suffering from fibromyalgia, and thus finding abnormal imaging or laboratory studies is rare [1]. As providers, it is our imperative to understand what has changed today to bring them into the Emergency Department. Doing so includes conducting a thorough history and physical to understand the duration, location, and severity of the pain and what treatment options the patient has pursued thus far. Any significant deviation from the patient’s baseline pain merits further evaluation to rule out acute pathology (e.g., chest pain may merit an acute coronary syndrome workup, joint pains may require further imaging). If an alternative cause of pain is found, it should be addressed accordingly. 

Fibromyalgia treatment can largely be pursued in an outpatient setting and is approached in a stepwise manner from nonpharmacologic treatments, to drug monotherapy, to combination drug therapies. Once other differentials for the patient’s pain have been safely ruled out, it is important to understand the next step in treatment. Initial outpatient management of fibromyalgia is pursued with nonpharmacologic treatments simultaneously with patient education, cognitive behavioral therapy, addressing comorbidities, and/or graded exercise programs [2]. Patient education should include information about their diagnosis, basic pathophysiology, and treatment options [3]. Patients should be reassured that their pain is secondary to a centralized pain and not secondary to injury or other pathology [4]. They should also be informed that other sleep and mood disorders are commonly associated with fibromyalgia and that concurrent treatment of those disorders would likely help with management of their symptoms [4]. Cognitive behavioral therapy involves cognitive restructuring and behavioral therapy to identify distressing thoughts to evaluate and address distorted thinking that may be exacerbating the pain [3]. Exercise programs that emphasize low impact aerobic activities such as walking, swimming, biking, or water aerobics [5]. It is important to acknowledge any attempts the patients have made to address their issues and to tailor treatment plans to better fit patients’ unique needs and capabilities. 

If nonpharmacologic treatments alone are ineffective, pharmacologic monotherapy treatment with tricyclic antidepressants such as amitriptyline can be initiated and escalated as needed and titrated to effect [6]. Given other comorbidities, other pharmacological treatments can be considered as well, especially if monotherapy is not adequately addressing the patient’s symptoms [2]. Serotonin-Norepinephrine Reputable Inhibitors (SNRIs) such as duloxetine or milnacipran and gabapentinoids such as pregabalin and gabapentin have proven to improve fibromyalgia symptoms [2]. Narcotic therapy should be avoided, given the limited physiologic mechanism, and consider the opiate epidemic throughout the country. 

This author was asked to write a commentary as the result of his publication surrounding childhood risk factors for developing fibromyalgia [7]. This work highlighted the significant relationship between complex childhood events and a future diagnosis of fibromyalgia. By making this connection, they are giving their physicians clues on how to help treat this disease. When encountering patients with fibromyalgia in the ED, it is critical to continue to listen to them and perform a thorough history and physical exam. These patients will continue to give us clues to the rest of their pathology, and guide us towards keeping them safe.

1. Clauw DJ (2014) Fibromyalgia: A clinical review. JAMA 311: 1547-1555.
2. Mascarenhas RO, Souza MB, Oliveira MX, Lacerda AC, Mendonça VA, et al. (2021) Association of Therapies With Reduced Pain and Improved Quality of Life in Patients With Fibromyalgia: A Systematic Review and Meta-analysis. JAMA Intern Med 181: 104-112.
3. Crofford LJ (2015) Psychological aspects of chronic musculoskeletal pain. Best Pract Res Clin Rheumatol 29: 147-155.
4. Bair MJ, Krebs EE (2010) Fibromyalgia. Ann Intern Med 172: ITC33-ITC48.
5. Häuser W, Klose P, Langhorst J, Moradi B, Steinbach M, et al. (2010) Efficacy of different types of aerobic exercise in fibromyalgia syndrome: A systematic review and meta-analysis of randomised controlled trials. Arthritis Res Ther 12: R79.
6. MacLean AJ, Schwartz TL (2015) Tramadol for the treatment of fibromyalgia. Expert Rev Neurother 15: 469.
7. Olivieri P, Solitaire B, Dubois M (2012) Childhood risk factors for developing fibromyalgia. Open Access Rheumatol 4:109-114.