Last updated: July 4, 2023

Summarytoggle arrow icon

Fibromyalgia is a chronic functional neurosensory disorder of unknown etiology. The pathophysiology is notable for pervasive symptoms despite the absence of identifiable inflammation or structural changes on physical exam, imaging, or histology. Cardinal symptoms include diffuse chronic musculoskeletal pain, fatigue, and unrefreshing sleep. Cognitive dysfunction (often called fibro fog), headaches, and morning stiffness are also commonly reported. Individuals with fibromyalgia often have comorbid conditions with overlapping clinical features (e.g., depressive disorders, migraine, irritable bowel syndrome). Since objective findings cannot be used to confirm or rule out fibromyalgia, the diagnosis relies on a thorough history of symptoms (i.e., character, duration, and severity). Although fibromyalgia is not a progressive illness, it can cause significant functional limitations and distress. Step-wise treatment begins with patient education, especially pertaining to exercise for which there is strong evidence to support a therapeutic effect. Additional treatments (e.g., physiotherapy and pharmacological therapy) and multidisciplinary pain management can be considered using shared decision-making.

Epidemiologytoggle arrow icon

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

The pathophysiology of fibromyalgia is not fully understood; its etiology is likely multifactorial. The interaction of the following factors may play a role: [3]

  • Genetic predisposition
  • Autoimmune [4]
  • Environmental triggers (e.g., physical or psychosocial stress)
  • Dysregulation of the neuroendocrine and autonomic nervous systems

Clinical featurestoggle arrow icon

Fibromyalgia manifests with chronic functional symptoms. Symptoms and severity vary between individuals, ranging from mild and intermittent to persistent and disabling.

Cardinal symptoms of fibromyalgia [5][6]

  • Diffuse chronic musculoskeletal pain
    • Distribution: all or most regions of the body
    • Character: variable, often neuropathic, without objective pathologic findings
  • Fatigue
  • Unrefreshing sleep

Common additional symptoms [5]

Diagnosticstoggle arrow icon

The diagnosis of fibromyalgia is based on symptoms alone. Imaging studies and biomarkers (e.g., ESR) are typically normal.

Clinical evaluation [5]

Eliciting pain at ≥ 11 of 18 tender points is a nonspecific finding and is no longer recommended in the assessment of fibromyalgia. [7]

Do not test patients for specific alternative conditions (e.g., Lyme disease) unless they have characteristic clinical features and appropriate history. [8]

Evaluation tools [5]

Numerous diagnostic criteria and validated tools for screening and assessment have been proposed but are not required for diagnosis.

  • Examples
    • 2016 ACR diagnostic criteria
    • Simplified Fibromyalgia Screening Questionnaire
    • Patient Health Questionnaire-15
  • Advantage: standardized assessments
  • Limitation: debated and uncertain clinical utility

Differential diagnosestoggle arrow icon

Comorbid conditions [7]

Several conditions share prominent clinical features with fibromyalgia and often occur simultaneously, e.g.:

Fibromyalgia and conditions with overlapping symptoms are not mutually exclusive and can occur simultaneously. [9]


Myofascial pain syndrome

  • Definition: : a chronic pain syndrome caused by muscle tension, injury, or repetitive motion and characterized by the presence of trigger points in muscles and/or fascia (small tender knots) [10]
  • Clinical features
    • Pain is mostly confined to one anatomical region: fewer tender points compared to fibromyalgia (≤ 11 of 18)
    • Leads to weakness and limited range of motion
    • Jump sign (myofascial pain syndrome): A physical examination finding characterized by an involuntary, sudden jerk or wince in response to stimulation of a tender area or trigger point (not seen in fibromyalgia).
    • Fatigue, headache, and sleep disturbances are less frequent compared to fibromyalgia
  • Treatment: physical therapy, massage, stretching, ice packs, NSAIDs

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon


  • Optimize patient education and supportive therapy for all patients.
  • Consider adding pharmacotherapy for severe pain and/or sleep disturbance refractory to nonpharmacological measures.
  • Engage a multidisciplinary team ; (e.g., rheumatology, psychiatry) for patients who do not achieve adequate relief.
  • For patients with new, worsening, or changing pain seen in ambulatory and emergency settings:
    • Follow the general approach to acute-on-chronic pain management.
    • Avoid repeating extensive diagnostic testing that has already been done (especially involving radiation or invasive procedures).
    • Consult the patient's regular provider(s) early and arrange follow-up.

Patient education [11]

  • Exercise: There is strong evidence to support the benefits of aerobic and strengthening exercises. [11][12]
  • Reassurance: Fibromyalgia is not a progressive illness and does not result from muscle or nerve damage.
  • Validation: Symptoms can be overwhelming and disabling.
  • Coping strategies, e.g., relaxation techniques
  • Sleep hygiene
  • See also “Patient encounters” in “Managing chronic conditions.”

Supportive therapy [11]

Pharmacological therapy [11]

NSAIDs and opioids (with the exception of tramadol) are generally ineffective and not recommended for the treatment of fibromyalgia. [8][11]

Referencestoggle arrow icon

  1. Bair MJ, Krebs EE. Fibromyalgia. Ann Intern Med. 2020; 172 (5): p.ITC33.doi: 10.7326/aitc202003030 . | Open in Read by QxMD
  2. Wolfe F, Clauw DJ, Fitzcharles M-A, et al. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum. 2016; 46 (3): p.319-329.doi: 10.1016/j.semarthrit.2016.08.012 . | Open in Read by QxMD
  3. Chandola HC, Chakraborty A. Fibromyalgia and myofascial pain syndrome-a dilemma.. Indian journal of anaesthesia. 2009; 53 (5): p.575-81.
  4. Jones GT, Atzeni F, Beasley M, Flüß E, Sarzi‐Puttini P, Macfarlane GJ. The Prevalence of Fibromyalgia in the General Population: A Comparison of the American College of Rheumatology 1990, 2010, and Modified 2010 Classification Criteria. Arthritis & Rheumatology. 2015; 67 (2): p.568-575.doi: 10.1002/art.38905 . | Open in Read by QxMD
  5. Arout CA et al.. Gender Differences in the Prevalence of Fibromyalgia and in Concomitant Medical and Psychiatric Disorders: A National Veterans Health Administration Study. Journal of Women's Health. 2018; 27 (8): p.1035-1044.doi: 10.1089/jwh.2017.6622 . | Open in Read by QxMD
  6. Bradley LA. Understanding Fibromyalgia and Its Related Disorders. Prim Care Companion J Clin Psychiatry. 2008; 10 (2): p.133-144.
  7. Goebel A, Krock E, Gentry C, et al. Passive transfer of fibromyalgia symptoms from patients to mice. J Clin Invest. 2021; 131 (13).doi: 10.1172/jci144201 . | Open in Read by QxMD
  8. Sarzi-Puttini P, Giorgi V, Marotto D, Atzeni F. Fibromyalgia: an update on clinical characteristics, aetiopathogenesis and treatment. Nat Rev Rheumatol. 2020; 16 (11): p.645-660.doi: 10.1038/s41584-020-00506-w . | Open in Read by QxMD
  9. Salaffi F, Di Carlo M, Farah S, et al. Diagnosis of fibromyalgia: comparison of the 2011/2016 ACR and AAPT criteria and validation of the modified Fibromyalgia Assessment Status. Rheumatology. 2020; 59 (10): p.3042-3049.doi: 10.1093/rheumatology/keaa061 . | Open in Read by QxMD
  10. Kodner C. Common questions about the diagnosis and management of fibromyalgia. Am Fam Physician. 2015; 91 (7): p.472-8.
  11. Macfarlane GJ, Kronisch C, Dean LE, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis. 2016; 76 (2): p.318-328.doi: 10.1136/annrheumdis-2016-209724 . | Open in Read by QxMD
  12. Bidonde J, Busch AJ, Schachter CL, et al. Aerobic exercise training for adults with fibromyalgia. Cochrane Database Syst Rev. 2017; 2017 (6).doi: 10.1002/14651858.cd012700 . | Open in Read by QxMD

Icon of a lock3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer