Playbook
What should I actually do about fibromyalgia?
Fibromyalgia is a real condition in which the nervous system amplifies pain, and it is far more common in women and often dismissed. There is no cure, but there is a genuine evidence base for what helps. This walks you through confirming it is fibromyalgia, ruling out the conditions that mimic it, and building a plan that actually works.
Fibromyalgia · reviewed July 2026 · 13 cited papers
See a clinician promptly if
- !Swollen joints, prolonged morning stiffness, rashes, or fever. Points to an inflammatory or autoimmune arthritis rather than fibromyalgia, and needs rheumatology assessment and blood tests.
- !New severe pain in one spot, unexplained weight loss, or night sweats. These are not typical of fibromyalgia and should be investigated to exclude other conditions.
- !A profound, delayed crash after minor exertion. Suggests ME/CFS overlap, where the usual advice to push through exercise can be harmful and activity needs careful pacing.
- !Severe low mood, hopelessness, or thoughts of self-harm. Chronic pain and depression often travel together. This deserves prompt mental health support, which is part of care, not a sign the pain is imaginary.
Step 1
Is it fibromyalgia, or something else?
Fibromyalgia is diagnosed from a pattern of symptoms, and part of the diagnosis is making sure something else is not causing them. Here is the picture that fits fibromyalgia, and the main conditions worth excluding, some of which can coexist with it.
Step 2
What to get checked
There is no blood test that confirms fibromyalgia. The point of testing is to exclude the conditions that mimic it, so a small, targeted panel is usually enough.
Thyroid function (TSH)
An underactive thyroid mimics fibromyalgia with fatigue and aches, and it is simple to test and treat.
Full blood count and inflammatory markers (ESR, CRP)
Screens for anemia and for the inflammation you would expect in autoimmune arthritis but not in fibromyalgia. Normal markers support the diagnosis.
Vitamin D
Deficiency is common, causes aches and fatigue, and is easy to correct.
Normal vs optimal. Correcting a deficiency is worthwhile general care, but do not expect it to resolve fibromyalgia on its own.
Further autoimmune tests only if there are specific signs
Tests like ANA or rheumatoid factor are only useful when there are clues to autoimmune disease, because false positives are common and can cause needless worry.
Step 3
What actually works
The strongest evidence is for a combined, active approach rather than any single pill. Guidelines put education and exercise first, with medication and therapy as add-ons for specific problems.
Understanding the condition
Learning that fibromyalgia is amplified pain processing, not damage, is itself part of treatment. It reduces fear, stops the endless search for a hidden injury, and makes the active steps below easier to stick with.
Exercise, built up gradually
Exercise is the single most strongly recommended treatment. Both aerobic activity (walking, cycling, swimming) and gentle strength training modestly reduce pain and improve function and quality of life. The art is starting well below what feels possible and increasing slowly.
TimelineWeeks to months. Expect some ups and downs before the trend improves.
How to get itOn your own or, ideally, with physiotherapy or a supervised program.
CautionsStarting too hard triggers flares. If a delayed crash after exertion dominates, pace carefully and get assessed for ME/CFS overlap first.
Cognitive behavioural therapy and pain programs
CBT and pain-focused psychological programs produce small but real reductions in pain, low mood, and disability, with some lasting benefit. Being offered this does not mean the pain is in your head; it is a skill for turning down a nervous system stuck on high.
TimelineA course over weeks to months.
How to get itReferral, or some structured self-guided programs.
Duloxetine or pregabalin
The best-studied medications. Duloxetine (an SNRI) and pregabalin each give meaningful pain relief to a minority of people. They are worth a monitored trial with a clear target, especially when pain, mood, or sleep are severe.
TimelineA few weeks to judge, at an adequate dose.
How to get itPrescription.
CautionsCommon side effects (nausea for duloxetine; dizziness, drowsiness, weight gain for pregabalin) make people stop. Both should be tapered rather than stopped abruptly. Much of the trial evidence was industry funded, which can flatter average benefit.
Low-dose amitriptyline
A cheap, long-used low bedtime dose of this tricyclic that helps some people, and can be especially worth trying when poor sleep drives the pain. The evidence is thin, but the cost and downside are low.
TimelineA few weeks; taken at night.
How to get itPrescription, off-label at low dose.
CautionsDry mouth and morning grogginess are common. Check for interactions with other medicines.
Opioids, including tramadol
Because the pain is centrally amplified rather than tissue-driven, opioids work poorly here, and the evidence for tramadol specifically has never been established. The risks (dependence, worsening pain over time) outweigh weak benefit.
CautionsIf you are already on an opioid, ask about a safe, gradual reduction rather than stopping suddenly.
Anti-inflammatories as a primary treatment
There is no inflammation to target in fibromyalgia, so NSAIDs and other anti-inflammatories tend to disappoint as a main treatment, even though they may help an unrelated ache.
Set your expectations
- No single treatment is a cure. The best results come from combining understanding, exercise, sleep, and sometimes medication or therapy.
- Exercise can briefly worsen symptoms before it helps. Ramp up slowly rather than abandoning it.
- Medications help a minority meaningfully. Trial one at a time with a clear goal, and stop it if it does not earn its place.
- Flares are part of the pattern. A good plan reduces how often they happen and how hard they hit, rather than promising they will never return.
Step 4
Take this to your doctor
“I have widespread pain, fatigue, and unrefreshing sleep, and I would like to be properly assessed for fibromyalgia and have the conditions that mimic it ruled out.”
Questions to ask
- Do I meet the fibromyalgia criteria, and what else should we exclude first?
- Can we check thyroid, blood count, inflammatory markers, and vitamin D?
- Can you help me start a gentle, graded exercise plan, ideally with physiotherapy?
- If we try medication, what counts as success and how long should I trial it?
What to bring
- A body map of where you have had pain over the past week
- A symptom log covering sleep, fatigue, and brain fog, and what makes flares better or worse
- A list of everything you have already tried
When to push. Ask for a rheumatology referral if there are inflammatory signs (swollen joints, prolonged morning stiffness, abnormal markers), and for a pain-management or psychology service if you are struggling to cope or function.
Step 5
Where the science is going
Low-dose naltrexone
Widely discussed online and well tolerated, but the best randomized trial to date, in women, did not clearly beat placebo for pain. It remains an experimental, off-label option rather than a proven treatment, so treat strong online claims with caution.
The nociplastic pain framework
Recognizing fibromyalgia as "nociplastic" pain (a distinct third category alongside injury and nerve-damage pain) is reshaping treatment toward the brain and nervous system and away from tissue-directed drugs and procedures. Expect future therapies aimed at how the nervous system processes pain.
All sources
Every claim above links to peer-reviewed research. Full list below.
- 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria (2016). Seminars in Arthritis and Rheumatism. doi.org/10.1016/j.semarthrit.2016.08.012
- Fibromyalgia: a clinical review (2014). JAMA. doi.org/10.1001/jama.2014.3266
- Nociplastic pain: towards an understanding of prevalent pain conditions (2021). Lancet. doi.org/10.1016/S0140-6736(21)00392-5
- Prevalence of fibromyalgia: a population-based study in Olmsted County, Minnesota, utilizing the Rochester Epidemiology Project (2013). Arthritis Care Res (Hoboken). doi.org/10.1002/acr.21896
- EULAR revised recommendations for the management of fibromyalgia (2017). Annals of the Rheumatic Diseases. doi.org/10.1136/annrheumdis-2016-209724
- Aerobic exercise training for adults with fibromyalgia (2017). Cochrane Database Syst Rev. doi.org/10.1002/14651858.CD012700
- Resistance exercise training for fibromyalgia (2013). Cochrane Database Syst Rev. doi.org/10.1002/14651858.CD010884
- Serotonin and noradrenaline reuptake inhibitors (SNRIs) for fibromyalgia (2018). Cochrane Database Syst Rev. doi.org/10.1002/14651858.CD010292.pub2
- Pregabalin for pain in fibromyalgia in adults (2016). Cochrane Database Syst Rev. doi.org/10.1002/14651858.CD011790.pub2
- Amitriptyline for fibromyalgia in adults (2019). Cochrane Database Syst Rev. doi.org/10.1002/14651858.CD011824
- Cognitive behavioural therapies for fibromyalgia (2013). Cochrane Database Syst Rev. doi.org/10.1002/14651858.CD009796.pub2
- Tramadol for management of fibromyalgia pain and symptoms: Systematic review (2020). International Journal of Clinical Practice. doi.org/10.1111/ijcp.13455
- Naltrexone 6 mg once daily versus placebo in women with fibromyalgia: a randomised, double-blind, placebo-controlled trial (2024). The Lancet Rheumatology. doi.org/10.1016/S2665-9913(23)00278-3
This playbook is educational and is not medical advice. Hair loss has many causes and individual treatment decisions belong with a clinician who can examine you.