Fibromyalgia
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Direct answer
Widespread pain with completely normal inflammatory markers points away from the joints and toward central pain amplification: fibromyalgia is chronic (three months or more) widespread pain with fatigue, unrefreshing sleep and cognitive complaint, diagnosed clinically by the 2016 ACR criteria — a Widespread Pain Index of 7 or more with a Symptom Severity Scale of 5 or more, or a WPI of 4–6 with an SSS of 9 or more. Examination and routine bloods are normal; ESR, CRP and creatine kinase are the triad that should make you look elsewhere. Management is education, graded aerobic exercise and cognitive behavioural therapy first, with pregabalin, duloxetine or milnacipran as drug options and low-dose amitriptyline the affordable Indian workhorse; opioids make things worse.
What you must remember
- 2016 criteria numbers: WPI 7 or more plus SSS 5 or more, or WPI 4–6 plus SSS 9 or more, with symptoms for at least three months; a coexisting rheumatological disease no longer excludes the diagnosis.
- The 1990 tender-point count is obsolete for diagnosis but still examined in India: eighteen points, nine paired — occiput, low cervical, trapezius, supraspinatus, second rib, lateral epicondyle, gluteal, greater trochanter and medial knee fat pad.
- Drugs with evidence: pregabalin 150–450 mg daily, duloxetine 30–60 mg and milnacipran — the only three licensed specifically for fibromyalgia in the US; low-dose amitriptyline 10–25 mg at night is standard Indian practice, cheap and effective on the sleep-pain loop.
- Non-drug measures come first: graded aerobic exercise has the strongest evidence of any intervention, followed by cognitive behavioural therapy and sleep hygiene.
- Exclude before labelling: hypothyroidism, vitamin D deficiency (rampant in India), anaemia and — when the story suggests it — rheumatoid arthritis, SLE or myositis; a raised ESR, CRP or CK is not fibromyalgia.
- Secondary fibromyalgia accompanies 10–30 per cent of RA and SLE patients: pain flaring with quiet joints and a normal CRP means treat the fibromyalgia, not escalate the immunosuppression.
- Opioids are avoided: regulators have warned of serious harms with opioids in this condition, and pain and function worsen on them.
How the consultation makes the diagnosis
Fibromyalgia is a history-first diagnosis, and the two most discriminating questions concern distribution and sleep. Ask the patient to mark every painful region — that is the Widespread Pain Index count — then grade fatigue, waking unrefreshed and cognitive symptoms from 0 to 3 each; that sum is the Symptom Severity Scale. A soft, diffuse tenderness without synovitis, normal muscle strength, and a normal ESR, CRP and CK close the loop. Order thyroid function and vitamin D once, treat what is deficient (in India, many will be), and do not order repeat ANA panels on the strength of pain alone.
Then the therapeutic conversation, which is itself treatment: the pain is real, the joints are not being damaged, and the goal is function first, not zero pain. Prescribe walking as a written dose — twenty minutes daily, escalating — and use the night drug for pain and sleep together. Review at six weeks with a function measure rather than a pain score, and expect improvement in weeks, not days.
How the exam frames it
The stem is nearly always a woman in her forties: widespread pain for years, multiple tender points, poor sleep, normal ESR, CRP and ANA — and the question is the next step, which is criteria-based diagnosis with exercise plus a low-dose tricyclic or pregabalin, not more investigations. The traps sit around it: a borderline ANA does not make lupus; a high ESR in an over-50 with shoulder and pelvic girdle pain points to polymyalgia rheumatica; and the RA patient with new widespread pain and a normal CRP should not have the biologic escalated — recognise the superimposed fibromyalgia. The viva favourite is naming the three licensed drugs.
Frequently asked questions
What are the 2016 ACR diagnostic criteria?
A Widespread Pain Index of 7 or more with a Symptom Severity Scale of 5 or more, or a WPI of 4–6 with an SSS of 9 or more, with symptoms lasting at least three months.
Which drugs are licensed for fibromyalgia?
Pregabalin, duloxetine and milnacipran; low-dose amitriptyline at night is widely used, especially in India, for cost and its sleep benefit.
Which investigations should precede the diagnosis?
Thyroid function, vitamin D, full blood count, ESR, CRP and creatine kinase, once — all expected normal; repeat serology is not indicated for pain alone.
Can fibromyalgia coexist with rheumatoid arthritis?
Yes, in 10–30 per cent of patients — pain out of proportion to synovitis with a normal CRP calls for fibromyalgia treatment, not immunosuppression escalation.
Are opioids useful in fibromyalgia?
No — regulators have warned of serious harms, pain and function worsen, and dependence compounds the sleep disorder.
How many tender points did the 1990 criteria count?
Eighteen, in nine bilateral pairs including occiput, trapezius, second rib, lateral epicondyle, gluteal, greater trochanter and knee — obsolete for diagnosis, still asked in Indian exams.