›Limit screens before bed
›Cool, dark, quiet sleep environment
›Stimulus control therapy — use bed only for sleep
›Unrefreshing sleep perpetuates central sensitization
Pharmacologic — optimize existing regimen
›FDA-approved fibromyalgia medications
›Duloxetine — SNRI
›30 mg daily for 1 week then 60 mg daily
›Titrate to 60 mg daily as maintenance and flare dose
›Maximum 120 mg daily in selected refractory cases
›Monitor for hypertension, serotonin syndrome, hepatotoxicity
›Milnacipran — SNRI
›12.5 mg daily day 1, then 12.5 mg twice daily days 2 to 3, then 25 mg twice daily
›Target 50 mg twice daily
›Maximum 100 mg twice daily
›Renal dose adjustment required for creatinine clearance below 30 ml/min
›Pregabalin — alpha-2-delta ligand
›75 mg twice daily initially
›Titrate to 150 mg twice daily over 1 week
›Maximum 225 mg twice daily
›Dose reduce for renal impairment — CrCl below 60 ml/min
›Caution — additive sedation with CNS depressants
Pharmacologic — acute flare adjuncts
›Cyclobenzaprine
›5 to 10 mg at bedtime
›Short-term muscle pain and spasm relief during flare
›5 mg preferred in elderly — anticholinergic effects
›Maximum 30 to 40 mg daily in divided doses
›Duration
›Short-term use during flare — 2 to 4 weeks
›Not for long-term maintenance
›Amitriptyline — off-label
›10 to 25 mg at bedtime
›Titrate to 25 to 50 mg over weeks
›Most effective for sleep and pain in low doses
›Avoid in elderly patients — Beers criteria anticholinergic concern
›Allow 6 to 8 weeks for full analgesic effect
›Response in sleep quality may be seen within 1 to 2 weeks
›Melatonin
›3 to 5 mg at bedtime for sleep disruption during flare
›Low side effect profile
›Helpful adjunct when sleep is a prominent trigger or symptom
›Acetaminophen
›500 to 1000 mg every 6 to 8 hours as needed
›Limited evidence for fibromyalgia pain but low risk
›Maximum 3000 to 4000 mg daily — hepatic function dependent
›Safer than NSAIDs for ongoing use in this population
›Opioids
›Not recommended for fibromyalgia
›Do not target central sensitization mechanism
›Risk of opioid-induced hyperalgesia — worsens pain long-term
›CDC 2022 opioid prescribing guideline recommends against for fibromyalgia
›If already prescribed, plan for dose reduction and alternative therapy optimization
›Taper plan in coordination with primary care or pain medicine
›NSAIDs
›Not superior to placebo for fibromyalgia pain per Cochrane review
›No role as primary fibromyalgia treatment
›Acceptable for comorbid musculoskeletal pain if not contraindicated
›Gastrointestinal and renal risks of chronic use
›Corticosteroids
›No role in fibromyalgia management
›Fibromyalgia is not an inflammatory condition
›Response to steroids suggests alternative inflammatory diagnosis
›If patient reports steroid responsiveness, reconsider fibromyalgia diagnosis
›Drug interactions to monitor
›SNRIs plus tramadol — serotonin syndrome risk
›Avoid combination unless carefully monitored
›If tramadol used, start at lowest dose and monitor
›Pregabalin plus CNS depressants — additive sedation
›Alcohol, benzodiazepines, opioids, antihistamines
Trigger management and lifestyle
›Stress management
›Acute stress identified as primary trigger — psychological intervention key
›Crisis counseling if acute psychosocial stressor
›Referral to mental health or social work
›Pacing strategies
›Activity pacing to prevent overexertion
›Scheduled rest periods — not prolonged bed rest
›Dietary considerations
›Adequate hydration and balanced nutrition
›Avoid excess caffeine and alcohol — worsen sleep quality
›Mediterranean diet associated with improvements in pain and fatigue
›Supplements with preliminary evidence
›Vitamin D replacement if deficient — target above 75 nmol/l
›Magnesium — limited evidence, low risk
›Evidence insufficient for standard recommendation
›Heat and physical modalities
›Warm bath or shower
›Muscle relaxation and pain relief during flare
›Hot packs to painful areas
›Transcutaneous electrical nerve stimulation
›Adjunct for localized pain — limited but low-risk