Pain Conditions

What is Fibromyalgia?

Fibromyalgia (FM) affects approximately 10–20 million individuals in the U.S. FM is a chronic condition associated with widespread pain and tenderness along with other symptoms such as problems with sleep, memory, mood, and fatigue. Women tend to be more susceptible to fibromyalgia, usually in middle age (20 years–50 years), and there is some evidence to suggest that it may run in families. If you have fibromyalgia, the pain and fatigue can affect many areas of your life including work, daily activities, enjoyment of hobbies, and taking care of your family. Currently there is no known cure for fibromyalgia, but the symptoms of FM can be managed successfully.

Symptoms

• Pain and tenderness: The most common symptoms of FM are widespread pain and tenderness. These symptoms tend to be highly variable with some days being better than others. The location of pain may also change over time - people often describe FM as “whole body pain” since the pain and tenderness of FM is not confined to a single location within the body.
• Fatigue: The fatigue of FM is described as both physical fatigue and mental fatigue. Both types of fatigue are described as being more profound than “general tiredness”. People with FM are more easily fatigable and when fatigued, slower to recover. People with FM fatigue often consider the fatigue to be as problematic as the pain.
• Sleep Problems: Some individuals with FM may have difficulty falling asleep or staying asleep. Others may sleep through the night but upon wakening, feel unrefreshed as though they were unable to sleep at all.
• Cognitive and Memory Problems: Problems with thinking (also referred to as “Fibro-Fog”) can take many forms including: difficulty concentrating, difficulty remembering, difficulty finding the right words for objects or people, mental cloudiness, difficulty navigating, and sensing that thinking is slower than usual.
• Depression and Anxiety: While FM used to be misdiagnosed as a variant of depression, depression and anxiety often co-exist with FM. When present, anxiety and depression can make FM symptoms worse. The depressive symptoms and anxiety do not need to be at the level of a diagnosable disorder to influence pain perception. Simply experiencing the symptoms of FM will likely have a negative impact on mood which in turn can make other FM symptoms worse.
• Sensory Sensitivity: In addition to pain, individuals with FM tend to experience hypersensitivity to light, sound, touch, taste, odors, and medications. This means that for people with FM, sensations will become unpleasant at intensities that do not bother other people. For example, individuals with FM may feel chilled or overly warm at temperatures that seem normal to others, movies or concerts may seem uncomfortably loud, or common perfumes may seem noxious.
• Stiffness: Stiffness upon wakening is common for individuals with FM. Stiffness can also occur after sitting or standing or when there are changes in barometric pressure.
• Dryness of Eyes or Mouth: Some individuals with FM report excessively dry eyes and/or mouth even when tear production or saliva is normal.
• Chronic Overlapping Pain Conditions (COPCs): If you have FM, you may also have one or more of the other COPCs found on this page. It is thought that these conditions may share common underlying causes.

What Causes FM?

About half of people with FM can identify some triggering event that they suspect led to the onset of FM. Others however report that FM started spontaneously - for no apparent reason.

Normally we experience pain when there is some injury (e.g., a broken bone, cut, or fall). This represents the body’s pain processing mechanism working adaptively to protect us from harm.

FM is an example of a disorder where sensory information (both normal and threatening) gets amplified by the brain. Thus in the case of FM, the problem is not necessarily an injury but a problem in how the brain processes nociceptive information and produces pain. The underlying problem in FM is thought to be nociplastic pain or centrally augmented pain, a disorder of pain processing.

It should be noted that pain experienced in response to an injury is indistinguishable from pain associated with central augmentation. Both are “real” forms of pain and both can result in comparable levels of suffering. Many factors can contribute to central pain augmentation including genetics, infections, hormonal abnormalities, physical and/or psychological trauma, repetitive injuries, and sustained physical/psychological stress.

Diagnosis of FM

Currently there are no reliable laboratory tests, x-rays, or other objective tests for diagnosing FM (even though there are some tests that purport to do so). In part this is because the problem is not the result of an injury or disease, but how the brain produces the experience of pain. Often individuals with FM will have seen many doctors before receiving a diagnosis of FM because FM can mimic many other illnesses. It is important to note however that you can have FM in addition to having other illnesses.

In the U.S., a doctor familiar with FM will typically take a careful medical history, and then utilize the diagnostic criteria from the American College of Rheumatology (ACR) to make the diagnosis of FM. These criteria take into account the following elements:

• The areas of your body in which you feel pain and its duration (e.g., pain wide-spreadedness)
• The presence of additional symptoms (e.g., fatigue, sleep problems, cognitive problems)

Who treats FM?

FM is often treated by family doctors, rheumatologists, or internists. While these doctors often coordinate the care, optimal care often requires a team approach. This team might include the following specialists:

• Rheumatologist – physicians specializing in arthritis and other diseases of the bones, joints, and muscles
• Nurse educators – specialists who can educate about the condition and help develop or refine a personalized treatment plan
• Physical therapists – specialists trained in mobilizing muscles, bones, and joints through exercise, hands-on care, and patient education
• Occupational therapists – specialists trained in teaching ways to protect joints, conserve energy, engage more fully in activities of daily living, and patient education.
• Psychologists or social workers – specialists who can help initiate and maintain self-care approaches to pain management and who can help address social challenges associated with dealing with chronic pain
• Dietitians - specialists who teach about optimal diets and maintaining a healthy weight
• Acupuncturists - specialists who may influence pain perception, promote healing, and improve functional status by stimulating specific points on the body often by inserting needles into the skin

Most importantly however YOU need to be a member of the team. Much of FM management can be done at home, by you, and does not require seeing a doctor. The parts that you can do may require some changes in how you live your life. You will need to stick to this plan for better pain control.

It is likely that you and your doctor will need to team up to identify the best combination of professional and self-care approaches that work for you. This plan will need to be reviewed and potentially revised over time as your needs shift.

Treatment of FM

The treatment/management of FM can take many forms. We identify the various approaches below. You can follow the links to learn more about each treatment/management strategy.

• Self-Care – There are many changes in your lifestyle that can help you to improve the symptoms of FM. What you choose to focus on needs to be personalized to your specific situation. The link above will take you to a description of the many self-management approaches others have found helpful. You may want to talk with your doctor to identify the self-care approaches that would be best for you at the present time.
• Professional Care – Combining self-care with professionally lead care can create an optimal approach to successful management of FM. The link above will take you to a description of the many professionally lead approaches to chronic pain management. For FM, the most common approaches include medications (e.g., anti-depressant, and anti-seizure), cognitive-behavioral therapy, and aerobic exercise.

Additional Resources

• American College of Rheumatology
• National Institute of Arthritis and Musculoskeletal and Skin Diseases, (NIH)
• National Fibromyalgia Association (NFA)
• National Fibromyalgia Partnership, Inc.
• Chronic Pain Research Alliance
• Chronic Pain and Fatigue Research Center (CPFRC)

Some Additional Reading

• Dr. Daniel Clauw provides a mechanistic review of FM and its treatment.
• Overview of non-pharmacological interventions for FM
• Using the Internet to deliver pain interventions.

What are Migraines?

Migraine is a neurovascular brain disorder affecting about 13% of people. Migraines are more than just really bad headaches. They are a collection of neurological symptoms that include severe throbbing pain, often on one side of the head, and can include nausea, vomiting, dizziness, visual disturbances, tingling or numbness in the extremities or face, and sensitivity to light, sound, smell, and touch.

What causes Migraines?

The exact causes of migraines are still unknown. It used to be thought that the dilation and constriction of blood vessels in the head were the primary cause of migraine pain. Therefore, early medicine focused on the blood vessels. It is now believed that migraines are caused by nerve pathways and brain chemicals.

There is growing evidence that migraines are hereditary. Individuals with a family history of migraines are at increased risk of having migraines. This genetic tendency for migraines results in a brain that is extra sensitive to stimuli that triggers a series of neurological events, such as abnormal firing of neurons, altered blood flow, and changes in levels of neurochemicals. Triggers vary greatly by person and over time.

Potential triggers include:

• Foods: alcohol, caffeine, chocolate, nitrates (found in processed meats like hot dogs and deli meat), artificial sweeteners, and monosodium glutamate or MSG (found in processed foods, canned foods, or Asian foods)
• Lifestyle: eye strain (especially from staring at a computer or TV for long periods of time), fatigue or lack of sleep, stress, dehydration, lack of physical activity, smoking, physical posture (e.g. sleeping in an unusual position, or sitting at a desk for a long time)
• Infection: cold, flu, or sinus infections
• Environmental: weather changes, allergens, bright or flickering lights, high altitudes, strong odors, and tobacco smoke
• Hormone fluctuations from menstruation, ovulation, menopause, pregnancy, birth control pills, and hormone replacement therapy

Types of Migraines:

The two major types of migraine are migraine without aura and migraine with aura. Aura is defined as neurological changes that occur prior to head pain. Aura symptoms may serve as warning signs for a headache. Aura symptoms tend to grow or spread gradually, usually lasting a few minutes to one hour (see below for more information on aura).

Here are some of the sub-types of migraines:

Migraine without aura (“common migraine”)

• Symptoms include pulsing or throbbing pain most often on one side of the head, nausea, vomiting, light and sound sensitivity, and pain that is made worse by physical activity.
• Lacks the warning phases (prodrome and aura)

Migraine with aura (“complicated migraine”, or “classic or classical migraine”)

• Headache is preceded by aura symptoms
• Occurs in about 25% of people with migraines
• Aura involves sensory changes, such as seeing flashing lights, zig zag lights, numbness, or vertigo. Please see below for more information on aura.

Migraine without head pain (“typical aura without headache”)

• Also called a Silent or Acephalgic Migraine.
• Aura symptoms are present without headache.

Hemiplegic Migraine:

• This type of migraine feels more like a stroke.
• People with this migraine develop weakness on one side of the body.
• Other common symptoms include the sensation of “pins and needles”, visual aura, and loss of sensation on one side of the body.
• May not include severe head pain.

Retinal Migraine:

• Temporary loss of vision in one eye.
• Most common in women during childbearing years.
• The blindness can last for as short as one minute to as long as months.
• There is little understanding about retinal migraine but it may be a sign of a more serious issue.

Chronic Migraine:

• More than 15 days a month with migraine.
• Symptoms and their severity may vary greatly on any given day.

What are the Phases of Migraine?

Prodromal Phase:

• Occurs hours or 1–2 days before the onset of head pain

• Symptoms may include:

  • Fatigue
  • Nausea
  • Blurred vision
  • Difficulty concentrating
  • Neck stiffness
  • Sensitivity to light and/or sound
  • Excessive yawning
  • Paleness

Aura Phase (not always present):

• Symptoms last a few minutes to one hour.

• Symptoms vary and may include:

  • Visual:

    • Occurs in over 90% of patients with migraine with aura
    • Zig zag lines or lights
    • Spots of flickering light
    • Blurred vision

  • Body sensations:

    • Pins and needles
    • Numbness, often in the hands and face

  • Cognitive, speech, language:

    • Often, people feel like they are not thinking clearly

    • Less frequently, people describe difficulty with written and spoken words

      • This may be difficulty in understanding what others are saying, putting words together, and/or processing written words
      • Some people may have slurred or garbled speech

  • Vertigo (a feeling of being off balance and dizziness)

  • Tinnitus (ringing or buzzing in the ear)

Headache Phase:

• Typically, throbbing pain on one side of the head. However, people can have pain on both sides of the head and without throbbing.
• Other common symptoms include nausea, vomiting, and sensitivity to light and sound.
• Without treatment, the headache may continue for up to 72 hours.

Postdromal Phase:

• Postdromal symptoms may occur after the headache and last for up to 48 hours.

• Also called the “migraine hangover”.

• There is less understanding of the Postdromal Phase.

• Symptoms may include:

  • Fatigue
  • Elated mood
  • Depressed mood
  • Achiness
  • Mental fogginess
  • Acute pain after coughing and sudden movements

Diagnosis:

Migraine is diagnosed by taking a careful assessment of the symptoms, reviewing family history, conducting medical tests, and eliminating other possible causes of the headache. Testing may include imaging from CT or MRI. Use of a headache diary can be a helpful tool for diagnosis and to better understand the frequency and severity of attacks, triggers, and responses to treatments.

Who treats Migraines?

Migraines are often treated by primary care or family medicine physicians and neurologists. Mental health providers trained in pain and headache treatments are often included in treatment and focus on techniques for managing pain, increasing quality of life, improving lifestyle behaviors that trigger or worsen symptoms, and decreasing stress.

Treatment of Migraines:

Although there is no current cure for migraines, there are treatments that help with preventing and managing symptoms. There is ongoing research on new migraine treatments (see American Migraine Foundation for more information).

• Short-term medications, such as triptans (e.g. sumatriptan, almotriptan) are used at the onset of migraine to try to stop a migraine once it has started or to decrease the symptoms. They are not used to prevent migraine, and are generally not useful for other types of pain, unless it is associated with migraine headache.

• Preventative medication focuses on reducing migraine frequency and severity. Several types of medications are approved to prevent migraines, and they work in different ways:

  • Anticonvulsants, also used to prevent seizures, such as valproic acid (e.g. Depakote) or topiramate (e.g. Topamax)
  • Botulinum toxin (Botox): periodic injections into the face and scalp.
  • Beta-blockers, which relax blood vessels, such as propranolol (e.g. Inderal) or metoprolol (e.g. Lopressor)
  • Calcium-channel blockers, which reduce the constriction of blood vessels, such as verapamil (e.g. Verelan) or diltiazem (e.g. Cardizem)

• Opioids are not recommended as a treatment for migraine due to lack of efficacy for migraines, their side effects, potential for dependence, and possible overdose death.

• It is important to use medications only as directed and not overuse medicine as this might lead to overuse (medication rebound) headaches and unwanted side effects.

• Non-medication preventative treatments include:

  • Trigger avoidance
  • Cognitive behavioral therapy
  • Biofeedback
  • Mindfulness-based therapy
  • Relaxation techniques
  • Behavioral therapy
  • Anti-inflammatory diet

• There are many new treatments currently being studied for migraines. For example, Cefaly is a new non-drug and non-invasive treatment for migraines. Cefaly is a device that is temporarily placed on the forehead and sends micro-impulses to the trigeminal nerve to relieve pain and prevent future migraines.

ADDITIONAL RESOURCES

American Migraine Foundation

• What Type of Headache Do I Have?
• The Science of Migraine – How to Deal With Postdrome
• What to Know About the New Anti CGRP Migraine Treatment Options
• Integrative and Complementary Migraine Treatments

Headache Classification Committee of the International Headache Society (HIS). 2013. The international classification of headache disorders, (beta version). Cephalalgia. 33:629–808. DOI: 10.1177/0333102413485658

International Headache Society