A Guide To Fibromyalgia Medications

Fibromyalgia is a complex syndrome that does not present the same set of symptoms, nor respond to the same medications, in each patient. It is therefore critical that before prescribing any medication, the healthcare professional must take a comprehensive medical history and complete a physical examination. Additional testing for sleep anomalies, neurological conditions and other co-morbidities will help the healthcare provider determine the best course of action. The examination will help determine which medication or medications are most likely to be effective in each patient.

Currently, no single medication alleviates all fibromyalgia symptoms. In June 2007, Lyrica (pregabalin) was the first medication to receive a listing for fibromyalgia from the FDA. Cymbalta (duloxetine) from Eli Lilly was listed by the FDA in June 2008 and Savella (milnacipran) was listed in January 2009. Other medications may be listed by the FDA in the coming months. Many other medications have also been tested in treating fibromyalgia, and are used effectively by caring professionals. Included here is a list of commonly used medications for the treatment of many fibromyalgia symptoms.

It takes time and communication between the healthcare professional and patient to determine the correct mix of medications and proper dosages for each patient. Healthcare professionals should encourage their patients to keep a detailed written journal of medications, dosages, timing, and side effects. Working as a team improves the chances of improving the quality of life for the patient.

FDA Listed

Medication:                Duloxetine hydrochloride/Cymbalta
Usage:                         anxiety, depression, sleep
Common Dosage:      20-60 mg/day
Mode of Action:         SNRI
References:                Arnold LM, Lu Y, Crofford LJ, Wohlreich M, Detke MJ, Lyengar S, Goldstein DJ. A double-blind, multicenter trial comparing duloxetine with placebo in the treatment of fibromyalgia patients with or without major depressive disorder. Arthritis and Rheumatism 2004; 50(9):2974-84

Russell, IJ, Mease PJ, Smith TR, Kajdasz DK, Wohlreich MM, Detke MJ, Walker DJ, Chappell AS, Arnold LM. Efficacy and safety of duloxetine for treatment of fibromyalgia in patients with or without major depressive disorder: Results from a 6-month, randomized, double-blind, placebo-controlled, fixed-dose trial.  Pain (2008 June) 136(3):432-44     

Medication:                Milnacipran/Savella
Usage:                         pain, depression
Common Dosage:      100-200 mg/day
Mode of Action:         SNRI
References:                Gendreau RM, Thorn MD, Gendreau JF, Kranzler JD, Ribeiro S, Gracely RH, Williams DA, Mease PJ, McLean SA, Clauw DJ. Efficacy of milnacipran in patients with fibromyalgia. Journal of Rheumatology 2005; 32(10):1975-85 

Clauw DJ, Mease P, Palmer RH, Gendreau RM, Wang Y.  Milnacipran for the treatment of fibromyalgia in adults: a 15-233k, multicenter, randomized, double-blind, placebo-controlled, multiple-dose clinical trial.  Clin Ther (2008 Nov) 30(11):1988-2004

Mease PJ, Clauw DJ, Gendreau RM, Rao SG, Kranzler J, Chen W, Palmer RH.  The efficacy and safty of milnacipran for treatment of fibromyalgia.  A randomized, double-blind, placebo-controlled trial.  J Rheum Feb 2009 36(2):398-409

Medication:                Pregabalin/Lyrica
Usage:                         fatigue, pain, sleep
Common Dosage:      450 mg
Mode of Action:         binds to the voltage-dependent calcium channel in CNS
References:                Crofford LJ, Rowbotham MC, Mease PJ, Russell IJ, Dworkin RH, Corbin AE, Young JP, LaMoreaux LK, Martin SA, Sharma U. Pregabalin for the treatment of fibromyalgia syndrome: results of a randomized, double-blind, placebo-controlled trial. Arthritis and Rheumatism 2005; 54(4):1264-73

 Crofford LJ, Mease PJ, Simpson SL, Young JP, Martin SA, Haig GM, Sharma U.  Fibromyalgia relapse evaluation and efficacy for durability of meaningful relief (FREEDOM): a 6-month, double-blind, placebo-controlled trial with pregabalin.  Pain (2008 Jun) 136(3):419-31

Mease PJ, Russell IJ, Arnold LM, Florian H, Young JP, Martin SA, Sharma U.  A randomized, double-blind, placebo-controlled, phase III trial of pregabalin in the treatment of patients with fibromyalgia.  J Rheumatol (2008 Mar) 35(3):502-14            

Commonly Used

Medication:                Alprazolam/Xanax     
Usage:                         depression, anxiety
Common Dosage:      0.25-3 mg/day
Mode of Action:         Acts at GABAA receptor
References:                Russell IJ, Fletcher EM, Michalek JE, McBroom PC, Hester GG. Treatment of primary fibrositis/fibromyalgia syndrome with ibuprofen and alprazolam: a double-blind, placebo-controlled study. Arthritis and Rheumatism 1991; 34(5):552-60        

Medication:                Amitriptyline/Elavil   
Usage:                         mild pain, sleep
Common Dosage:      10-50 mg/day
Mode of Action:         inhibits reuptake of serotonin and noradrenaline
References:                Carette S, Bell MJ, Reynolds WJ, Haraoui B, McCain GA, Bykerk VP, Edworthy SM, Baron M, Koehler BE, Fam AG, et al. Comparison of amitriptyline, cyclobenzaprine, and placebo in the treatment of fibromyalgia. A  randomized, double-blind clinical trial. Arthritis and Rheumatism 1994; 37(1):32-40

Medication:                Bupropion hydrochloride/Wellbutrin
Usage:                         fatigue, fibro fog
Common Dosage:      slow release 150-300 mg/day
Mode of Action:         serotonin receptor agonist
References:                Ott GE, Rao U, Lin KM, Gertsik L, Poland RE. Effect of treatment with bupropion on EEG sleep: relationship to antidepressant response. Int J Neuropsychopharmaology 2004; 7(3):275-81             

Medication:                Carisoprodol/Soma   
Usage:                         skeletal muscle relaxation, pain
Common Dosage:      350 mg, 1-4 x day
Mode of Action:         unknown, metabolite is meprobamate
References:                Toth PP, Urtis J. Commonly used muscle relaxant therapies for acute low back pain: a review carisoprodol, cyclobenzaprine hydrochloride, and metax-alone. Clinical Therapeutics 2004; 26(9):1355-67

Medication:                Clonazepam/Klonopin           
Usage:                        anxiety, RLS, sleep
Common Dosage:      0.25-2 mg
Mode of Action:         simulates action of GABA on the CNS
References:                Ohanna N, Peled R, Rubin AH, Zomer J, Lavie P. Periodic leg movements in sleep: effect of clonazepam treatment. Neurology 1985; 35(3):408-11

Tesar GE, Rosenbaum JF. Successful use of clonazepam in patients with treatment-resistant panic disorder. Journal of Nervous and Mental Disease 1986; 174(8):477-82

Medication:                Cyclobenzaprine/Flexeril      
Usage:                         muscle relaxation, mild pain, sleep
Common Dosage:      5-30 mg
Mode of Action:         unknown, potentially increases norepinephrine release
References:                Tofferi JK, Jackson JL, O'Malley PG. Treatment of fibromyalgia with cyclobenzaprine: a meta-analysis. Arthritis and Rheumatism 2004; 51(1):9-13

Medication:                Dextromethorphan/Benylin  
Usage:                         pain
Common Dosage:      30-120 mg/day
Mode of Action:         weak NMDA receptor antagonist
References:                Ilkjaer S, Dirks J, Brennum J, Wernberg M, Dahl JB. Effect of systemic N-methyl-D-aspartate receptor antagonist (dextromethorphan) on primary and secondary hyperalgesia in humans. British Journal of Anaesthesia 1997; 79(5):600-5

Medication:                Dicyclomine hydrochloride/Bentyl   
Usage:                        IBS, pain
Common Dosage:      20 mg
Mode of Action:         blocks muscarinic receptors
References:                Hennessy WB. A comparative study of two dicyclomine preparations in functional bowel disorders. Medical Journal of Australia 1975; 2(11):421-3

Medication:                Doxepine HCl/Sinequan       
Usage:                         depression, muscle spasms
Common Dosage:      75-150 mg/day
Mode of Action:         inhibits reuptake of serotonin & noradrenaline, weak inhibition of reuptake of dopamine
References:                Roth T, Zorick F, Wittig R, McLenaghan A, Roehrs T. The effects of doxepine HCl on sleep and depression. Journal of Clinical Psychiatry 1982; 43(9):366-8

Medication:                Eszopiclone/Lunesta 
Usage:                        sleep
Common Dosage:      2-3 mg
Mode of Action:         simulates action of GABA on the CNS
References:                Najib J. Eszopiclone, a nonbenzodiazepine sedative-hypnotic agent for the treatment of transient and chronic insomnia. Clinical Therapeutics 2006; 28(4):491-516

Medication:                Fludrocortisone/Florinef       
Usage:                        neurally mediated hypotension, fatigue, nausea
Common Dosage:      0.1 mg
Mode of Action:         synthetic corticosteroid
References:                Raj SR, Rose S, Ritchie D, Sheldon RS. The second prevention of syncope trial (post II) - a randomized clinical trial of fludrocortisone for the prevention of neurally mediated syncope: rationale and study design. American Heart Journal 2006; 151(6):1186

Medication:                Fluoxetine/Prozac      
Usage:                        depression, anxiety
Common Dosage:      10-80 mg/day
Mode of Action:         SSRI
References:                Arnold LM, Hess EV, Hudson JI, Welge JA, Berno SE, Keck PE. A randomized, placebo-controlled, double-blind, flexible-dose study of fluoxetine in the treatment of women with fibromyalgia. American Journal of Medicine 2002; 112(3):191-7

Medication:                Gabapentin/Neurontin          
Usage:                        neuropathic pain
Common Dosage:      900-3600 mg/day in 3 divided doses
Mode of Action:         bind to voltage-dependent calcium channel in CNS
References:                Arnold LM, Goldenberg DL, Stanford SB, Lalonde JK, Sandhu HS, Keck PE, Welge JA, Bishop F, Stanford KE, Hess EV, Hudson JI. Gabapentin in the treatment of fibromyalgia: a randomized, double-blind, placebo-controlled, multicenter trial. Arthritis and Rheumatism 2007; 56(4):1336-44

Medication:                Mirtazapine/Remeron          
Usage:                        antidepressant, pain, sleep, fatigue
Common Dosage:      7.5-15 mg
Mode of Action:         blocks presynaptic alpha-2 adrenergic receptors
References:                Samborski W, Lezanska-Szpere M, Rybakowski JK. Effects of antidepressant mirtazapine on fibromyalgia symptoms. Rocz Akad Med Bialymst 2004; 49:265-9

Medication:                Modafinil/Provigil     
Usage:                        severe daytime fatigue or fibro fog
Common Dosage:      200-400 mg in am
Mode of Action:         unknown, potentially neuroprotective
References:                Schwartz JR, Hirshkowitz M, Erman MK, Schmidt-Nowara W. Modafinil as adjunct therapy for daytime sleepiness in obstructive sleep apnea: a 12-week, open-label study. Chest 2003; 124(6):2192-9

Medication:                Nortriptyline HCl/Pamelor   
Usage:                        depression, sleep
Common Dosage:      75-100 mg/day, max 150 mg
Mode of Action:         inhibits reuptake of serotonin and lesser effect on reuptake of norepinephrine
References:                Bondarell W, Alpert M, Friedhoff AJ, Richter EM, Clary CM, Batzar E. Comparison of sertraline and nortriptyline in the treatment of major depression disorder in late life. American Journal of Psychiatry 2000; 157(5):729-36

Medication:                Paroxetine HCl/Paxil
Usage:                         depression, pain
Common Dosage:      10 mg in am
Mode of Action:         SSRI
References:                Patkar AA, Masand PS, Krulewicz S, Mannelli P, Peindl K, Beebe KL, Jiang W. A randomized controlled, trial of controlled release paroxetine in fibromylagia. American Journal of Medicine 2007; 120(5):448-54

Medication:                Pramipexole dihydrochloride/Mirapex        
Usage:                       RLS
Common Dosage:      0.125-1.5 mg at dinnertime
Mode of Action:         non-ergoline dopamine agonist
References:                Holman AJ, Myers RR. A randomized, double-blind, placebo-controlled trial of pramipexole, a dopamine agonist, in patients with fibromyalgia receiving concomitant medications. Arthritis and Rheumatism 2005; 52(8):2495-505

Medication:                Pyridostigmine bromide/Mestinon   
Usage:                         normalizes growth hormone response to exercise
Common Dosage:      60-180 mg
Mode of Action:         initiate calcium influx and release of acetylcholine
References:                Paiva E, Deodhar A, Jones K, Bennett R. Impaired growth hormone secretion in fibromyalgia patients evidence for augmented hypothalamic somatostatin tone. Arthritis and Rheumatism 2002; 46(5):1344-1350

Jones KD, Burckhardt CS, Deodhar AA, Perrin NA, Hanson GC, Bennett RM.  A six-month randomized controlled trial of exercise and pyridostigmine in the treatment of fibromyalgia.  Arthritis Rheum (2008 Feb) 58(2):612-22

Medication:                Ropinirole hydrochloride/Requip     
Usage:                        RLS
Common Dosage:      0.5-2 mg/day
Mode of Action:         non-ergoline dopamine agonist
References:                Bogan RK, Fry JM, Schmidt MH, Carson SW, Ritchie SY. Ropinirole in the treatment of patients with restless legs syndrome: a US-based randomized, double-blind, placebo-controlled clinical trial. Mayo Clinic Proceedings 2006; 81(1):17-27

Medication:                Sertraline hydrochloride/Zoloft        
Usage:                         depression, anxiety
Common Dosage:      50-200 mg/day
Mode of Action:         SSRI
References:                Allgulander C, Dahl AA, Austin C, Morris PL, Sogaard JA, Fayyad R, Kutcher SP, Clary CM. Efficacy of sertraline in a 12-week trial for generalized anxiety disorder. American Journal of Psychiatry 2004; 161(9):1642-9

Medication:                Sodium oxybate/Xyrem        
Usage:                        sleep
Common Dosage:      4.5-6 mg. repeat 3-4 hours later
Mode of Action:         unknown, but GHB immediate precursor to GABA
References:                Russell IJ, Bennett RM, Michalek JE, oxybate for FMS study group. Sodium oxybate relieves pain and improves sleep in fibromyalgia syndrome (FMS): a randomized, double-blind, placebo-controlled, multi-center clinical trial. American College of Rheumatology Annual Meeting; November 2005

Russell IL, Perkins AT, Michalek JE, and the Oxybate SXB-26 Fibromyalgia Syndrome Study Group.  Sodium oxybate relieves pain and improves function in fibromyalgia syndrome.  Arthr & Rheum (Jan 2009) 60(1):299-309

Medication:                Sumatriptan/Imitrex  
Usage:                         migraine
Common Dosage:      50-100 mg/day
Mode of Action:         stabilizes serotonin levels in the brain, 5-HT agonist
References:                Winner P, Mannix LK, Putnam DG, McNeal S, Kwong J, O'Quinn S, Richardson MS. Pain-free results with sumatriptan taken at the first sign of migraine pain: 2 randomized, double-blind, placebo-controlled studies. Mayo Clinic Proceedings 2003; 78(10):1214-22

Medication:                Tizanidine hydrochloride/Zanaflex
Usage:                         muscle relaxation, mild pain, sleep
Common Dosage:      4-8 mg
Mode of Action:         alpha-2 adrenergic agonist
References:                Leiphart JW, Dills CV, Levy RM. Alpha-2-adrenergic receptor subtype specificity of intrathecally administered tizanidine used for analgesia for neuropathic pain. Journal of Neurosurgery 2004; 101(4):641-7

Mukand JA, Giunti EJ. Tizanidine for the treatment of intention myoclonus: a case series. Archives of Physical Medicine and Rehabilitation 2004; 85(7):1125-7

Medication:                Topiramate/Topamax
Usage:                         migraine
Common Dosage:      25-100 mg
Mode of Action:         enhances GABA-activated chloride channels
References:                Brandes JL, Kudrow DB, Rothrock JF, Rupnow MF, Fairclough DL, Greenberg SJ. Assessing the ability of topiramate to improve the daily activities of patients with migraine. Mayo Clinic Proceedings 2006; 81(10):1311-9

Medication:                Tramadol hydrochloride with acetaminophen/Ultracet
Usage:                         mild to moderate pain
Common Dosage:      37.5 mg every 4-8 hours, not to exceed 300 mg/day
Mode of Action:         acts on GABAergic, noradrenergic and serotonergic systems
References:                Bennett RM, Kamin M, Karim R, Rosenthal N. Tramadol and acetaminophen combination tablets in the treatment of fibromyalgia pain: a double-blind, randomized, placebo-controlled study. American Journal of Medicine 2003; 114(7):537-45

Bennett RM, Schein, J, Kosinski, MR, Hewitt DJ, Jordan DM, and Rosenthal NR.   Impact of fibromyalgia pain on health-related quality of life before and after treatment with tramadol/acetaminophen.  Arthritis & Rheumatism 2005; 53(4):519-527

Medication:                Tramadol hydrochloride/Ultram
Usage:                         mild to moderate pain
Common Dosage:      50-100 mg every 4-8 hours, not to exceed 400 mg/day
Mode of Action:         acts on GABAergic, noradrenergic and serotonergic systems
References:                Turturro MA, Paris PM, Larkin GL. Tramadol versus hydrocodone-acetaminophen in acute musculoskeletal pain: a randomized, double-blind clinical trial. Annals of Emergency Medicine 1998; 32(2):139-4

Medication:                Trazodone hydrochloride/Desyrel
Usage:                         depression, sleep
Common Dosage:      50-150 mg/day
Mode of Action:         serotonin reuptake inhibitor
References:                Rawls WN. Trazodone (Desyrel, Mead-Johnson Pharmaceutical Division). Drug Intelligence and Clinical Pharmacy 1982; 16(1):7-13

Zavesicka L, Brunovsky M, Horacek J, Matousek M, Sos P, Krajca V, Hoschl C.  Trazodone improves the results of cognitive behaviour therapy of primary insomnia in non-depressed patients

Medication:                Venlafaxine HCl/Effexor
Usage:                         depression
Common Dosage:      25 mg in am
Mode of Action:         SNRI
References:                Sayar K, Aksu G, Ak I, Tosun M. Venlafaxine treatment of fibromyalgia. Annals of Pharmacotherapy 2003; 31(11):1561-5

Medication:                Zolpidem/Ambien
Usage:                        sleep
Common Dosage:      5-15 mg
Mode of Action:         binds to GABA receptors
References:                Moldofsky H, Lue FA, Mously C, Roth-Schechter B, Reynolds WJ. The effect of zolpidem in patients with fibromyalgia: a dose ranging, double-blind, placebo controlled, modified crossover study. Journal of Rheumatology 1996; 23(3):529-33

Medication:                Zonisamide/Zonegran
Usage:                         neuropathic pain
Common Dosage:      100-400 mg
Mode of Action:         unknown, potentially blocking repetitive firing of voltage-gated sodium channels
References:                Krusz JC. Treatment of chronic pain with zonisamide. Pain Pract 2003; 3(4):317-20

Limited/Occasional Use

Medication:                Ketamine/Ketanest
Usage:                        pain
Common Dosage:      100 mg/ml in saline, 1-2 sprays every 8 hours.  50-200 mg at bed
Mode of Action:         noncompetitive NMDA receptor antagonist
References:                Graven-Nielsen T, Aspegren Kendall S, Henriksson KG, Bengtsson M, Sorensen J, Johnson A, Gerdle B, Arendt-Nielsen L. Ketamine reduces muscle pain, temporal summation, and referred pain in fibromyalgia patients. Pain 2000; 85(3):483-91

Wood PB. A reconsideration of the relevance of systemic low-dose ketamine to the pathophysiology of fibromyalgia. The Journal of Pain 2006; 7(9):611-614

Medication:                Memantine/Namenda
Usage:                            pain
Common Dosage:      30 mg
Mode of Action:         NMDA receptor antagonist, uncompetitive antagonist of seratonin
References:                Wiech K, Kiefer RT, Topner S, Preissl H, Braun C, Unertl K, Flor H, Birbaumer N. A placebo-controlled randomized crossover trial of the N-methyl-D-aspartic acid receptor antagonist, memantine, in patients with chronic phantom limb pain. Anesthesia and Analgesia 2004; 98(2):408-13

Bigal M, Rapoport A, Sheftell F, Tepper D, Tepper S.  Memantine in the preventive treatment of refractory migraine.  Headache (2008 Oct) 48(9):1337-42

Medication:                Nabilone/Cesamet
Usage:                         Pain
Common Dosage:      1 mg bid
Mode of Action:         cannabinoid
References:                Skrabek RQ, Galimova L, Ethans K, Perry D.  Nabilone for the treatment of pain in fibromyalgia. J of Pain (Feb 2008) 9(2):164-173

Medication:                Pindolol/Visken
Usage:                            pain, stiffness, sleep
Common Dosage:      7.5-15 mg/day
Mode of Action:         nonselective beta blocker
References:                Wood PB, Kablinger AS, Caldito GS. Open trial of pindolol in the treatment of fibromyalgia. The Annuals of Pharmacotherapy 2005; 39:1812-1816

Medication:                Quetiapine/Seroquel
Usage:                            stiffness, fatigue, sleep, anxiety, mood
Common Dosage:      25-100 mg/day
Mode of Action:         SNRI
References:                Hidalgo J, Rico-Vallademoros F, Calandre EP.  An open-label study of quetiapine in the treatment of fibromyalgia.  Prog in Neuro-Psychopharm and Biol Psych 30 Jan 2007) 31(1): 71-77

Calandre EP, Morillas-Arques P, Rodriguez-Lopez CM, Rico-Vallademoros F, Hildago J.  Pregabalin augmentation of quetiapine therpy in the treatment of fibromyalgia: an openlabel, prospective trial.  Pharmacopsychiatry (2007 Mar) 40(2):68-71.


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