Medications For Treating The Pain Of Fibromyalgia

The severe and chronic pain of fibromyalgia is considered to be one of the most problematic and debilitating aspects of the condition. Managing pain effectively for those with fibromyalgia is essential to promote healthy sleep habits and to improve the overall quality of life. However, effective fibromyalgia pain management is extremely difficult because of the way that the body responds to the specific type of pain.

Typically over the counter types of pain medications and even commonly used prescription pain medications have little value in lowering the pain levels for people with fibromyalgia. Pain not associated with fibromyalgia is often reduced with the use of the medications, but the specific pain of the condition remains constant for most individuals even using opiate and narcotic types of prescription medications. Different options for pain management and treatment are therefore one of the major factors in current clinical trials for fibromyalgia.

Tender Point Injections and Trigger Point Injections

Tender points are the areas of the body that, when pressed or often even when not under pressure, tend to cause various levels of pain from mild to severe in people with fibromyalgia. Tender points cannot be seen and there is rarely any swelling, redness or inflammation. On the other hand trigger points, which are a diagnostic feature of myofascial pain syndrome, tend to be hard nodules that can be detected under the skin. Pressing on a tender point causes pain at that location of the body while pressing on a trigger point causes pain along the muscle. As many people with fibromyalgia also have myofascial pain syndrome, trigger and tender point injections may be an effective way to minimize pain.

Trigger points can be detected by manual palpation by the medical professional or though the use of guided imagery and manual palpation in combination. Tender points are detected through the use of manual palpation and the American College of Rheumatology guidelines. Most studies have shown that there is very little effect in injecting tender points. However, there is evidence that trigger point injections can be useful. When the trigger points are identified, a small amount, usually 3 to 5 ml, of a local anesthetic is injected into the area. The relief from pain occurs within minutes and is typically long lasting. Injections are often combined with increased physical or massage therapy to increase the range of motion without the pain and discomfort of the trigger points. Research also indicates that treating trigger has a much wider effect on overall pain reported by patients with both fibromyalgia and myofascial pain syndrome.1

In recent studies several research teams have proposed that trigger points are actually present in patients with fibromyalgia, but they may be active or latent. This also supports the use of trigger point injections as a way to address the entire pain patterns of both conditions, which are similar in their overall expression. 2

Topical Skin Treatments

Transdermal medications are applied to the surface of the skin and absorbed into the bloodstream without going through the digestive system. They can be applied as creams, gels or lotions and may also be available in a small sized patch that provides long term pain medications. Some research indicates that specific topical medications may be effective in some people in limiting the action of the peripheral nerves and pain receptors, minimizing the pain messages and misinterpretations that occur in the central nervous system and the brain of those with fibromyalgia.  However, there is also research that indicates some topical skin treatments are not effective.

The transdermal pain medications can be over the counter or they can also be prescribed by a doctor. There are over the counter pain patches that may be effective for mild symptoms of fibromyalgia and can also be helpful in allowing the person to get a good night’s sleep.

Prescription patches include a 5% lidocaine option. The 5% lidocaine patches are generally well tolerated but need to be used for longer periods of time before the positive effects are noted.3 This is true for both fibromyalgia patients and those with myofascial pain syndrome or a combination of the two conditions.

Antidepressants

Antidepressants are commonly used to alleviate the widespread chronic pain of fibromyalgia and to help to limit the number of flares. Three different categories of antidepressants can be used in the treatment of fibromyalgia pain including tricyclic antidepressants (TCA), selective serotonin reuptake inhibitors (SSRI) and serotonin and norepinephrine reuptake inhibitors (SNRI).

All three types of antidepressants can be helpful in lowering chronic pain and increasing sleep and the restful quality of sleep that is often a major factor for individuals with fibromyalgia. Tricyclic antidepressants (TCA) are the most commonly prescribed and they are relatively well tolerated by most people. They tend to have fewer side effects and fewer counterindications for use.

TCAs, SNRIs and SSRIs are prescribed in a low dose and may be beneficial in increasing energy levels, assisting in a good night’s sleep as well as addressing possible issues of depression. They may also be prescribed in combination to cover a wider range of symptoms.

Cymbalta®. (duloxetine), Savella®. (milnacipran) and Lyrica®. (pregabalin) are currently the only FDA approved medications for fibromyalgia. Cymbalta®. and Savella®. are both SNRIs, while Lyrica®. was originally approved as an anti-seizure medication, but is most commonly used for nerve induced pain.

Pain Medications

Because pain is often the primary symptom for fibromyalgia patients, many different treatments have been tried. Standard anti-inflammatory medications like Motrin®., ibuprofen, alieve®., and naproxen have shown little to no benefit with fibromyalgia patients. Medications like Tylenol®. (acetaminophen) can help some, but often fibromyalgia patients still have significant pain. Narcotics have also been used, but they have not shown any benefit long term. They may take away the pain briefly, but they have significant side effects and addiction potential. One final option that has had some success in recent trials has been Ultram®. (tramadol). Ultram®. has similar effects as narcotic pain medications, but often has fewer side effects. In fact, the American Pain Society recommends Ultram®. for fibromyalgia patients, but does not recommend stronger narcotic medications.

Most people with fibromyalgia will use a combination of pain management techniques and medications to address both the chronic pain and the pain flares that can occur. Often over the counter medications can supplement or support prescription medications, and in turn therapy, low intensity exercise and diet and lifestyle monitoring and changes can help to effectively manage the pain of fibromyalgia.

Working with your medical team to determine which medications and treatments are most effective in treating your fibromyalgia pain is important. While it can be discouraging going through the necessary trail and error testing to find the combination that is best for you, it really is worth the effort.

References

1 Staud, R. (2006). Are Tender Point Injections Beneficial: The Role of Tonic Nociception in Fibromyalgia. Current Pharmaceutical Design , 23-27.

2 Ge, H.-Y. (2010). Prevalence of Myofascial Trigger Points in Fibromyalgia: The Overlap of Two Common Problems. Current Pain and Headache Reports , 339-345.

3 Affaitati, G., Fabrizio, A., Savini, A., et al. (2009). A randomized, controlled study comparing a lidocaine patch, a placebo patch, and anesthetic injection for treatment of trigger points in patients with myofascial pain syndrome: Evaluation of pain and somatic pain thresholds. Clinical Therapeutics , 705-720

This article was originally published on July 11, 2012 and last revision and update of it was 9/7/2015