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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Fibromyalgia

Rheumatology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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New emergency is not fibromyalgia

Suicidal intent, rapidly progressive weakness, sphincter dysfunction, a hot swollen joint, sepsis, acute chest pain or a new focal neurological deficit must not be absorbed into a chronic fibromyalgia label.

Action: Assess the acute syndrome independently, complete immediate physical and mental-health observations, and activate the appropriate emergency, sepsis, neurological, joint or crisis pathway while continuing respectful pain care.

Synopsis

Make a positive clinical diagnosis of fibromyalgia, explain nociplastic pain without dismissing symptoms, perform proportionate testing for mimics, build graded non-pharmacological care, and avoid medicines that provide little durable benefit or create dependence.

  • Fibromyalgia causes chronic widespread pain with fatigue, non-restorative sleep, cognitive symptoms and sensory sensitivity; examination may show diffuse tenderness but no required tender-point count.
  • Make a positive clinical diagnosis after history, full examination and proportionate tests show no better explanation; it can coexist with inflammatory or structural disease.
  • Widespread Pain Index and Symptom Severity scores can structure assessment, but complement rather than replace clinical judgement and exclusion of important mimics.
  • Explain nociplastic amplification: pain is real, but ongoing symptoms do not mean muscles and joints are being progressively damaged by ordinary movement.
  • Offer supported graded aerobic and strengthening activity, pacing that avoids boom-and-bust cycles, sleep intervention and, when appropriate, ACT or CBT for pain.
  • NICE allows consideration of selected antidepressants after shared discussion, even without depression; use low doses, define a target and review adverse effects and withdrawal.
  • Do not initiate opioids, gabapentinoids, benzodiazepines, NSAIDs or paracetamol specifically for chronic primary pain; review existing treatment safely rather than stopping abruptly.
  • Investigate new focal, inflammatory, neurological or systemic features independently; fibromyalgia should reduce neither vigilance nor access to ordinary care.

Key red flags

Objective progressive weakness, upper-motor-neurone signs, saddle sensory change or new bladder dysfunction requires urgent neurological or spinal assessment.

Persistent fever, weight loss, focal night pain, lymphadenopathy, inflammatory joint swelling or markedly abnormal inflammatory markers suggests infection, malignancy or inflammatory disease.

Current suicidal thoughts with intent, inability to maintain safety or severe medicine withdrawal needs same-day mental-health and medical risk assessment.

New exertional chest pain, syncope, hypoxaemia or unilateral limb swelling requires acute cardiopulmonary assessment rather than attribution to sensitisation.

Investigation priorities

01
First-line clinical criteriaFirst stepFirst line

Document widespread symptom burden and duration while finding objective features indicating another or coexisting condition.

Management branches

First-line diagnosisName the syndrome and retain vigilance

Widespread pain, sleep disturbance, fatigue and cognitive symptoms have persisted for at least three months.

  1. Take a whole-person history and perform musculoskeletal, neurological and general examination, documenting both typical clustering and discordant objective features.
  2. Use symptom criteria to support a positive diagnosis and request only focused tests needed for common mimics or history-led alternatives.
  3. Explain that altered processing produces genuine pain without requiring continuing tissue damage while preserving a route to assess new focal or systemic change.
  4. Agree the most important functional problem and a small initial treatment target rather than an unmanageable dense package.
Preferred non-drug treatmentRebuild activity, sleep and control

The diagnosis is sufficiently accepted to begin rehabilitation and no unstable alternative limits participation.

  1. Start low-intensity aerobic or strengthening activity below the level provoking prolonged flare, then increase one variable gradually with support when needed.
  2. Replace overactivity-and-collapse cycles with planned pacing, consistent waking and recovery while maintaining valued work, family and social roles.
  3. Offer ACT or CBT for pain when accessible, focusing on coping, sleep, fear, mood and valued action rather than proving a psychological cause.

Key medicines

Amitriptyline off-labelStart 10 mg orally at night, increasing after one to two weeks to 20–25 mg at night if needed and tolerated; review after four to eight weeks and taper if ineffective.Sedation, dry mouth, constipation, urinary retention, blurred vision, falls and QT effects limit use, especially in older adults; avoid MAO inhibitors and seek advice in pregnancy, bipolar disorder or suicide risk.
Duloxetine off-labelStart 30 mg orally once daily for one to two weeks, then increase to 60 mg once daily if tolerated; review by four to eight weeks and taper gradually when stopping.Check blood pressure, liver and renal disease, bleeding medicines, hyponatraemia and serotonergic combinations; nausea, insomnia, sexual dysfunction and withdrawal occur, and reproductive advice is needed.
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG193 Chronic pain recommendationsAssessment, exercise, psychological therapy and medicines.
  • Royal College of Physicians fibromyalgia guidanceUK positive diagnosis and proportionate differential assessment.
  • NHS FibromyalgiaSymptom recognition and multidisciplinary care.
  • EULAR revised fibromyalgia recommendationsEvidence grading for exercise, psychological therapy and medicines.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
  • Address sleep apnoea, restless legs, depression, anxiety, trauma, obesity or hypermobility as parallel treatable contributors.