The key insight: The primary source of fibromyalgia pain is not in the back or neck or head or stomach or legs, where the pain is typically felt--but rather is inside the brain. And that points to solutions.
WHERE THE PAIN IS REALLY COMING FROM
While people with fibromyalgia may suffer pain all over their bodies, the primary cause of the pain stems from the way the central nervous system interprets sensory input. Painful stimuli...or even just touch...gets intensified in the brain and spinal cord. It's like a stereo system that keeps turning up its own volume.
The evidence: Two neurotransmitter chemicals--glutamate and substance P, which increase the transmission of pain signals--are too high in people with fibromyalgia. Other neurotransmitters, including serotonin, norepinephrine, and GABA (gamma-aminobutyric acid), which decrease pain transmission, are--you guessed it--too low in people with the condition. Brain imaging studies show that when patients with fibromyalgia are given a mild pressure or heat stimulus, the pain-processing areas of their brains light up. In people without fibromyalgia, they don't.
There is still debate, of course. There are new findings that people with fibromyalgia have abnormalities in the peripheral nervous system, which sends signals from the arms, legs and organs to the brain. However, even proponents of peripheral involvement now agree that the central nervous system plays an important role.
WHY OPIOIDS BACKFIRE
Patients with fibromyalgia often don't get relief from traditional pain relievers, such as nonsteroidal anti-inflammatory drugs (NSAIDs), which can be effective for peripheral pain syndromes such as typical headaches or muscle aches but help only about one-third of patients with chronic pain such as fibromyalgia.
Opioid drugs are even worse. The reason: The body is already overproducing its own natural opioids released in response to chronic pain. These natural painkillers are flooding the system, filling up the body's opioid receptors, so there are few places for synthetic opioids to land. This chronic overstimulation of the body's opioid system, originating in the brain, may contribute to the progress of fibromyalgia.
"There has never been a study showing that opioids are effective for fibromyalgia," says Dr. Clauw. In fact, by contributing to this overstimulation, synthetic opioids may even increase pain in people with fibromyalgia. Indeed, in some studies, a low dose of the opioid-blocking medication naltrexone has provided fibromyalgia relief. Heaping on synthetic opioids, as many doctors have tried (and patients have asked for), just makes the overstimulation worse. "Giving more opioids might be akin to throwing kerosene on a fire," says Dr. Clauw.
The more effective treatments have included drugs that target neurotransmitters. But even these drugs shouldn't play the primary role in a fibromyalgia treatment plan. Rather, the focus should be on lifestyle modification and mind-body therapies that help manage stress, incorporate exercise and help improve sleep.
It's not just general "healthy living" advice, but based on rigorous research on what works for this specific medical condition. To evaluate the treatments that have the best scientific evidence, Dr. Clauw conducted a clinical review of all relevant studies on fibromyalgia from 1955 through 2014. Treatment approaches were then rated based on the quality of the studies. Says Dr. Clauw, "Pharmacological therapies can be helpful in alleviating some symptoms, but patients rarely achieve meaningful improvements without adopting these core self-management strategies."
RETRAINING YOUR BRAIN WITHOUT DRUGS
Lifestyle and mind-body approaches that help with fibromyalgia have something in common--they all help restore a balance of neurotransmitters in the brain and central nervous system. They literally change the brain. Says Dr. Clauw, "Brain imaging studies are showing more and more that these approaches can affect brain function." They are not only just as effective as medication, he says, but almost always are safer and less expensive.
The following approaches are particularly effective in treating fibromyalgia:
- Exercise. It's not easy to become more active when you're in pain --not to mention often sleep-deprived because of your discomfort--but it really helps. The best approach is to "start low, go slow," focusing first on increasing daily activity such as walking a little more than you usually do, then building up slowly so that you develop more aerobic endurance. While aerobic exercise has been best studied for fibromyalgia, Dr. Clauw notes that strength-training and stretching have also been shown to be of value. Exercise boosts brain levels of norepinephrine and helps reduce stress.
- Cognitive Behavioral Therapy (CBT). Fear of pain can make pain worse. This form of "talk therapy" helps patients learn new ways to think about how they feel, and that affects brain function and can reduce pain. CBT is effective in fibromyalgia whether it's one-on-one, in groups or even through online programs. It is important to understand that CBT is not primarily a "psychological" intervention in this context, but an approach that can help change how the brain interprets pain signals.
- Complementary and alternative therapies. These include tai chi, yoga, water-based massage such as Watsu and acupuncture. While these have not been rigorously studied for fibromyalgia, Dr. Clauw believes that they are effective for many patients.
Getting a good night's sleep is also key to balancing neurotransmitters and feeling better. Of course, there's a Catch-22 to this advice: When pain keeps you up at night, it's awfully tough to get the sleep you need. To help fibromyalgia patients understand how to work through the challenges of this disease and reduce stress, get more exercise, sleep better and use other nondrug strategies, Dr. Clauw and his colleagues at the University of Michigan have created a free online Fibroguide. It includes ways to personalize your plan.
Daniel Clauw, MD, is a professor of anesthesiology, medicine (rheumatology) and psychiatry, and director of the Chronic Pain and Fatigue Research Center, both at the University of Michigan, Ann Arbor. He is internationally recognized for his expertise on how the central nervous system contributions to chronic pain. His clinical review, titled "Fibromyalgia: A Clinical Review," was published in JAMA.