Fibromyalgia

Question 1

🎯 Essence

Answer 1

Chronic widespread pain, fatigue, and fibrofog due to central sensitisation — not inflammatory or autoimmune.

Question 2

🧬 Pathophysiology

Answer 2

↓ serotonin/noradrenaline/dopamine; ↑ substance P/glutamate; descending inhibitory failure (PAG–RVM).

Question 3

🧠 Imaging

Answer 3

fMRI shows insula/cingulate/thalamic hyperactivation proportional to pain severity (JAMA Netw Open 2023).

Question 4

🌿 Peripheral

Answer 4

Small-fiber neuropathy in ~50% confirms peripheral contribution (Pain 2023).

Question 5

😴 Sleep

Answer 5

Non-restorative sleep → ↓ GH/IGF-1 → fatigue & myalgia.

Question 6

⚙️ Triggers

Answer 6

Trauma, infection, stress, hormonal changes, genetic susceptibility (HLA-B62, SERT polymorphism).

Question 7

👩‍⚕️ Clinical Features

Answer 7

Pain >3mo, fatigue, fibrofog, stiffness, IBS, paresthesia; ESR/CRP/CK/TSH normal.

Question 8

📊 Epidemiology

Answer 8

2–4% adults; female 9:1; age 30–55; 25% of rheumatology referrals.

Question 9

🧪 Diagnosis

Answer 9

ACR 2016: WPI≥7 & SS≥5 or WPI4–6 & SS≥9; ≥3mo; no alternative diagnosis.

Question 10

🚨 Not FM

Answer 10

CK↑→myositis; ANA+→SLE/RA; TSH↑→hypothyroid; ESR>40→PMR/malignancy; wt loss→malignancy.

Question 11

⚕️ Management 1

Answer 11

Education, validation, graded aerobic exercise ≥150min/wk, sleep hygiene, CBT/ACT/mindfulness.

Question 12

⚕️ Management 2

Answer 12

SNRIs (duloxetine/milnacipran) ↓ pain; pregabalin ↑ sleep; amitriptyline/cyclobenzaprine for sleep.

Question 13

⚕️ Management 3

Answer 13

Low-dose naltrexone 4.5mg HS (off-label; Rheumatology 2022); avoid opioids/steroids.

Question 14

💊 Combination

Answer 14

SNRI + pregabalin > monotherapy (J Pain 2023 meta-analysis).

Question 15

🧠 Psychological

Answer 15

CBT + exercise synergistic (Lancet Psych 2023); ACT for relapse prevention.

Question 16

💪 Regional Pain

Answer 16

Localised enthesopathy (tennis elbow, trochanteric bursitis, plantar fasciitis); manage rest → physio → topical NSAID → US-guided CS if persistent.

Question 17

🩺 Red Flags

Answer 17

Weakness/CK↑, synovitis/ANA+, TSH↑, ESR>40, wt loss/fever = not FM.

Question 18

📈 Prognosis

Answer 18

Chronic, non-progressive; 30–50% improve; regional pain self-limited with rehab.

Question 19

📊 EBM Stats

Answer 19

Duloxetine NNT~6; Pregabalin NNT~7; Amitriptyline NNT~8; relapse~50%@6mo (Cochrane 2024).

Question 20

💡 Exam Clues

Answer 20

Normal ESR/CRP/CK/TSH; pain≫fatigue; no steroids/opioids; screen Vit D/B12/ferritin/OSA.

Question 21

⭐ Pearls

Answer 21

Exercise = treatment, not test; set activity-based goals; correct deficiencies; check sleep/mood.

Question 22

📚 Evidence

Answer 22

NEJM2022 Duloxetine; NEJM2021 Pregabalin; Rheumatology2022 LDN; JPain2023 combo; LancetPsych2023 CBT+exercise.

Question 23

🧠 Mnemonic FIBRO

Answer 23

F–Fatigue/Fog, I–Insomnia, B–Body pain≥3mo, R–Rule-out inflammation, O–Optimise mind-body therapy.