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.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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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.
Key red flags
Objective progressive weakness, upper-motor-neurone signs, saddle sensory change or new bladder dysfunction requires urgent neurological or spinal assessment.
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.
Take a whole-person history and perform musculoskeletal, neurological and general examination, documenting both typical clustering and discordant objective features.
Use symptom criteria to support a positive diagnosis and request only focused tests needed for common mimics or history-led alternatives.
Preferred non-drug treatmentRebuild activity, sleep and control
The diagnosis is sufficiently accepted to begin rehabilitation and no unstable alternative limits participation.
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.
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.
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.