Fibromyalgia

BOSTON -- When a diagnosis of irritable bowel syndrome comes to mind, consider migraine, fibromyalgia, and depression as well.

My patient complains of chronic fatigue. Her complete blood cell count and thyroid-stimulating hormone level are normal. Would it be worthwhile to measure her dehydroepiandrosterone sulfate (DHEA-S) level?

Monday morning your nurse hands you charts for 4 new patients. Each patient is a woman with widespread body pain, stiffness, and fatigue. All have already been evaluated by another physician and were advised that they should reduce stress and practice distraction techniques. They are in your office today seeking a second opinion.

An 82-year-old woman complains that for the past 6 months, she has "not felt like herself." Previously, she was very active and energetic; in fact, 9 months earlier, she had vacationed in Hawaii. It now takes all of her energy just to get out of bed.

ABSTRACT: The management of chronic daily headache is difficult and complex. Those affected have a sensitive nervous system, and their predisposition for a low tolerance to sensory stimuli appears to be inherited. Under appropriate conditions, the equilibrium or balance between bombardment from painful stimuli and the regulatory systems that inhibit those stimuli is disrupted, allowing painful stimuli to become manifest at a greater intensity than in the nonmigraineur. Successful management depends on close adherence to nonpharmacologic approaches and pharmacologic regimens that desensitize the system and restore equilibrium. Comorbid conditions must be identified and treated as well.

The diagnosis and treatment of migraine as its own entity is a complicated and delicate balance between identification and management. The situation is more complex, however, when the patient with migraine presents with comorbid conditions (eg, mood, neurologic, or musculoskeletal pain disorders). These comorbid conditions have important clinical implications. In fact, the risk of these and other comorbid disorders is much higher for migraineurs than for persons without a history of migraine. Comorbid conditions can also complicate treatment in some patients because of the potential for drug interactions or exacerbation of one condition by therapy for the other. The onus is on the physician to consider migraine treatment regimens that include the potential to manage underlying comorbidities and, conversely, to consider treatment regimens when migraine itself may be secondary to other primary symptoms.

Treatment of fibromyalgia syndrome (FMS) is a challenge. However, most patients benefit from appropriate management. Essential to treatment are a physician's positive and empathetic attitude, continuous psychological support, patient education, patience, and a willingness to guide patients to do their part in management. Other important aspects involve addressing aggravating factors (eg, poor sleep, physical deconditioning, emotional distress) and employing various nonpharmacologic modalities (eg, regular physical exercise) and pharmacologic therapies. Drug treatment includes use of tricyclic medications alone or in combination with a selective serotonin reuptake inhibitor, and other centrally acting medications. Tender point injection is useful. It is important to individualize treatment. Management of FMS is both a science and an art.

ABSTRACT: The results of diagnostic tests do not correlate well with the presence and severity of pain. To avoid missing a serious underlying condition, look for "red flags," such as unexplained weight loss or acute bladder or bowel function changes in a patient with low back pain. Nonopioid medications can be more effective than opioids for certain types of pain (for example, antidepressants or anticonvulsants for neuropathic pain). When NSAIDs are indicated, cyclooxygenase-2 inhibitors are better choices for patients who are at risk for GI problems or who are receiving anticoagulants. However, if nonspecific NSAIDs are not contraindicated, consider using these far less expensive agents. The tricyclic antidepressants are more effective as analgesics than selective serotonin reuptake inhibitors. When opioids are indicated, start with less potent agents (tramadol, codeine, oxycodone, hydrocodone) and then progress to stronger ones (hydromorphone, fentanyl, methadone, morphine) if needed.

How effective are NSAIDs in the treatment of fibromyalgia?

ABSTRACT: Once you have excluded a cardiac origin of chest pain, focus the evaluation on esophageal, psychiatric, musculoskeletal, and pulmonary causes. Gastroesophageal reflux disease (GERD) and esophageal motility disorders are the most common causes of unexplained chest pain (UCP). If you suspect an esophageal disorder, empiric antisecretory therapy is the most cost-effective initial approach. If the patient remains symptomatic, order a 24-hour esophageal pH study with symptom analysis while the patient receives maximal acid suppression. Once GERD is excluded, the patient may be treated for visceral hyperalgesia with low-dose tricyclic antidepressants or standard doses of selective serotonin reuptake inhibitors. Panic disorder-the most common psychiatric disorder in patients with UCP-is often associated with atypical symptoms, such as palpitations and paresthesias, and other psychiatric disorders. If you suspect panic disorder, one approach is to give the patient a short-term, nonrefillable prescription for a benzodiazepine and refer him or her for psychiatric evaluation.

ABSTRACT: Fibromyalgia syndrome (FMS) is a common condition that causes chronic pain and disability. It should be diagnosed by its own clinical characteristics of widespread musculoskeletal pain and multiple tender points. American College of Rheumatology criteria guidelines are most helpful in diagnosing FMS. The major symptoms are pain, stiffness, fatigue, poor sleep, and those of other associated conditions, for example, irritable bowel syndrome, headaches, restless legs syndrome, chronic fatigue syndrome, and depression. The pathophysiology of FMS is thought to involve central sensitization and neuroendocrine aberrations, triggered or aggravated by genetic predisposition; trauma; psychosocial distress; sleep deprivation; and peripheral nociception.

Consider a concentrated solution(10 mg/mL) of doxepin for patientswith fibromyalgia who experienceside effects with other tricyclics ateven 10-mg doses.

ABSTRACT: Systematic palpation can detect a trigger point; often, muscle spasms or a nodule will be present. Injection of the trigger point with a local anesthetic usually reduces pain promptly; the procedure can also effect long-term pain relief and increased range of motion. However, pain may recur and even worsen 1 to 3 days after an injection-either because additional injections are needed or because the trigger point was not completely injected. To maintain pain relief and improve strength and range of motion in the affected muscle following injection, recommend stretching exercises, physical or massage therapy, or rest. Trigger point injections can be associated with adverse effects (eg, temporary numbness, injection site irritation, and dizziness); complications include vasovagal syncope, skin infection, and compartment syndrome.