Kitaj Headache Center, LLC
...finding the balance
When I graduated from neurology residency at Yale, I opened a headache center. But I soon saw that my migraine patients had a 60-80% chance of also having fibromyalgia so I began treating fibromyalgia.

Q: The first question patients with fibromyalgia ask is “Do you think fibromyalgia is  psychological or biological? Both sides of the argument
The answer is that no physician can give them a perfect answer as we do not have all the facts yet.
Q: Is it psychological?  Both sides of the argument
YES, it is psychological:
KG Raphael1 found that the prevalence of major depression in women with fibromyalgia was 3 fold higher than in people without fibromyalgia.
H Cohen and L Neumann2 found that 57% of their fibromyalgia patients had PTSD symptoms.
RH Gracely and DA Williams3 found that catastrophizing augments pain perception in fibromyalgia patients

NO, it is not psychological, it is biological:
The Jensen study4 found that depression, anxiety, catastrophizing did not correlate with rating of clinical pain, nor with sensitivity to pressure pain. Neurotransmitter substances (substance P is too high, serotonin is too low) are out of normal ranges in these patients.

My Opinion:
Once the neurons in the brain and the nerves become overly sensitized to pain, the patient feels severe pain. Both psychological and biological reasons contribute to causing the over-sensitivity of the nerves and the brain, and often, not always, a combination of psychological and non-psychological methods can be used to retrain the pain parts of the brain back to health.

Q: How is fibromyalgia defined?
American College of Rheumatology, in 2010, has defined fibromyalgia as symptoms present for 3 or more months and absence of another disorder that would explain the pain.
- Tender point exam is NOT required anymore

- WPI  (Widespread Pain Index), 19 areas of the body which experience pain were checked and summed up
- Areas include jaw L/R, neck, shoulder L/R, upper arm L/R, lower arm, L/R, chest, upper back, lower back, hip L/R, abdomen, upper leg L/R, lower leg L/R
- The SSS (Symptom Severity Scale)
- Fatigue (0-3)
- Waking unrefreshed (0-3)
- Cognitive symptoms (0-3)
- Somatic symptoms (0-3)
- ACR Guidelines total score = WPI > = 7 and SSS > = 5
- Or WPI  = 3-6 and SSS  > = 9
- 2010 ACR criteria are 93% accurate, 97% sensitivity and 92% specificity.

Previously American College of Rheumatology, in 1990, defined fibromyalgia as pain for 3 months
Pain on the right and left sides of the body
Pain above and below the waist (including shoulder and buttock pain)
Pain in the axial skeleton (cervical, thoracic or lumbar spine, or chest)
Pain on palpation with a 4-kg/cm2 force in 11/18 sites (nine bilateral sites, for a total of 18 sites):
At the tendinous insertions of muscles: trapezius, sternocleidomastoid, splenius capitus, semispinalis capitus
Low cervical: at the anterior aspect of the interspaces between the transverse processes of C5-C7
Trapezius: at the midpoint of the upper border
Supraspinatus: above the scapular spine near the medial border
Second rib: lateral to the second costochondral junctions
Lateral epicondyle: 2 cm distal to the lateral epicondyle
Gluteal: at the upper outer quadrant of the buttocks at the anterior edge of the gluteus maximus muscle
Greater trochanter: posterior to the greater trochanteric prominence
Knee: at the medial fat pad.

Q: What are other symptoms of fibromyalgia?
Fatigue, insomnia (can fall asleep, but have frequent arousals during night, and do not feel refreshed even with 8-10 hours sleep), exercise intolerance, AM stiffness, most common back pain > neck shoulder; patients feel that their joints are swollen, even though measuring the joint does not show swelling, migraine or tension headache, tingling limbs (paresthesias); aggravation by anxiety, weather,  precipitated by caffeine, alcohol, chocolate, usually 30-50 years old; women more than men, leg cramps, poor immediate recall and concentration, decreased ability to multi-task

Q: What is the definition of Tender points?
- 11/18 symmetrical  tender points  painful over muscles, tendons, bone,  pain on muscle tendon insertion point and at muscle bellies on 4 KG/cm2 of digital pressure.
- Fibromyalgia patients can only tolerate 1-3 kg, whereas a normal patient would tolerate 5-15 kg before they experience pain at the lateral epicondyle
- most common tender point = superior medial scapula
- Tender point counts will vary as a function of menstrual cycle phase.5

Q: What other conditions are associated with fibromyalgia?
Irritable bowel (60%), headaches, dysmenorrhea,  Raynaud’s, Chronic Fatigue Syndrome (CFS), depression, anxiety, arthritis, mitral valve prolapse, restless leg syndrome (31%), systemic lupus erythematous, TMJ, myofascial pain syndrome. Chronic Fatigue Syndrome meet criteria for fibromyalgia, and more than 50% of patients  with fibromyalgia also have a current or past diagnosis of CFS.6

Q: What  kind of  sleep problems are associated with fibromyalgia?
Sleep is classified into Stages I-IV, and REM (Rapid eye movement) during dreams. The most refreshed sleepers get more stage III and IV sleep.  Light sleepers, are easily aroused because they have less deep Stage III and IV sleep, so are not refreshed after sleep. Alpha waves are the class of waves showing that the patient is awake, not sleeping. However, for fibromyalgia patients, alpha waves are seen in what should be the deepest stages of sleep, intruding into stages III, IV.  Alpha delta EEG pattern is common in fibromyalgia patients who spend 2.5 times more in sleep that shows alpha waves than normal sleepers. When healthy patients were deprived of Stage III and IV sleep, and alpha delta sleep was enforced on them, they also had aching muscles, and tenderness, stiffness.

Q: What diseases are similar to fibromyalgia and  have to be ruled out?
Ankylosing spondylitis (prominent neck, spine, and back pain and stiffness)
Entrapment neuropathy / thoracic outlet (diffuse paresthesias and pain)
Growth Hormone Deficit - Growth hormone was low in fibromyalgia patients (Bennett 1992). Symptoms are deconditioning, labile mood, fatigue, obesity Hypothyroidism (can have tenderness over tender point areas, along with other areas)
Myofascial pain can occur along with fibromyalgia. Myofascial pain is in small areas of trigger points in individual muscles, not widespread pain like in fibromyalgia)
Pelvic pain
Polymyalgia rheumatica (limb girdle and shoulder stiffness and pain)
Polymyositis (diffuse myalgias, weakness on exercise)
Rheumatoid arthritis (symmetric joint pain, sensation of swelling, AM stiffness)
Statin myopathy

Q: What labs have to be collected on a Fibromyalgia patient?
- ESR. Thyroid Function Tests, CBC, SMA7, CA, MG, PO3, CK, SPEP, ANA, RH Factor.
- 1/3 of  patients have low Insulin growth factor, an indication of low growth hormone, secreted during Stage III-IV sleep
- low cortisol because of alteration in hypothalamus-pituitary-adrenal axis.

Q: Other testing findings: spinal tap, muscle biopsy, not commonly tested?
- Muscle biopsy:  nonspecific changes, such as type II fiber atrophy, abnormal Z bands, ragged red fibers, local muscle hypoxia, as seen with altered metabolism and blood flow.
- Lumbar Puncture / CSF:  increased substance P (Russell, 1994), decreased serotonin, increased NGF, increased glutamate (Sarchielli 2007)
- decreased serotonin in plasma, increased serotonin reuptake on platelets,
- high percentage of neurally mediated hypotension, tilt table testing done

Q: What are treatments for fibromyalgia?
- Acupuncture  - studies showing no benefit7 vs. study showing benefit8 in fibromyalgia symptoms with acupuncture: results of a randomized controlled trial..

- Aerobic exercise (Busch 2008)
- biofeedback and other behavioral therapy, CBT (Rossy, 1999)
- chiropractic treatment
- Cyclobenzaprine (Flexeril) : more effec  than placebo  in decreasing pain
- Duloxetine (Cymbalta)  (Arnold, 2004)
- Fluoxetine  (Prozac)- combo of fluoxetine  20 mg+ amitriptyline 25 mg showed superior results to either alone in FIQ scores
- Gabapentin  (Neurontin) = in doses 300-1200 mg (Arnold, 2007)
- Milnacipran (Savella) mixed NE and serotonin  reuptake inhibitor (Vitton 2004)
- Pregabalin (Lyrica) (Arnold, 2008)
- Psychotherapy Thieme K and Gracely RH, 2009 Curr Rheumatol Rep
Reviewed 14 randomized trials of fibromyalgia treatment: highest effect sizes for pain reduction in CBT, OBT; Relaxation = not useful; Hypnotherapy and writing intervention= mild treatment effects
- PT: spray fluoromethane + stretch to desensitize spindle
- Tricyclics  (Amitriptyline, Nortriptyline, Desipramine) (Arnold,2000)- Tizanidine (Zanaflex) 2  mg = is as effective as 100 mg amitriptyline. Tizanidine works by reduction of substance P (Russell, 2002)
- Venlafaxine ( Effexor) Mixed norepinephrine and serotonin reuptake inhibitor
1 Raphael KG. Psychiatric comorbidities in a community sample of women with fibromyalgia. Pain, 2006.124:117-25
2 Cohen H, Neumann L. Prevalence of post-traumatic stress order in fibromyalgia patients: overlapping syndromes or post-traumatic fibromyalgia syndrome?, Semin Arthritis Rheum,2002.32:38-50
3 Gracely RH and Williams DA, Biology and therapy of fibromyalgia. Functional magnetic resonance imaging findings in fibromyalgia, Arthritic Research & Therapy 2006, 8:224. Can also be found at http://arthritis-research.com/content/8/6/224
4 Jensen KB, Anxiety and depressive symptoms in fibromyalgia are related to poor perception of health but not to pain sensitivity or cerebral processing of pain, Arthritis & Rheumatism, 2010, 62:3488-3495. Can also be found at http://onlinelibrary.wiley.com/doi/10.1002/art.27649/abstract
Hapidou E, Rollman G. Menstrual cycle modulation of tender points. Pain, 1998.77:151-161
6  Goldenberg D, Simms R, Geiger A, Komaroff A. High frequency of fibromyalgia in patients with chronic fatigue syndrome seen in a primary care practice. Arthritis & Rheumatology 1990. 33: 381-38
7 Assefi, N.P. A Randomized Cllinical Trial of Acupuncture compared with Sham acupuncture in Firbromyalgia. Annals of Internal Medicine; 2005, 143:10-19.
Martin, DP,  Mayo Clin Proceedings. 2006