At this time, there are no drugs approved to specifically treat fibromyalgia. Rather, doctors frequently — and legally — prescribe medications approved for other illnesses to treat symptoms of different conditions. The practice is known as off-label use. That's why many of the drugs you'll read about in this chapter were originally approved to treat other conditions. But rest assured, many of these therapies have been successful in treating fibro symptoms in other people. Even better, some of them work on several symptoms at once.
You go to your doctor complaining of pain and fatigue. He prescribes you an antidepressant. If you think your doctor has you pegged as someone who's simply depressed, think again. Antidepressants are one of the most commonly prescribed medications for the treatment of fibromyalgia because they can actually work on several fronts — to treat pain, improve sleep, and reduce your other symptoms, including depression. They are probably the most effective medications for long-term treatment of anxiety, too. They can even work on other symptoms such as irritable bowel syndrome and interstitial cystitis. That's because the neurotransmitters that regulate our mood — serotonin, norepinephrine, and epinephrine — are the same ones that control pain and sleep. But not all antidepressants are the same. In fact, these medications fall under several categories.
Tricyclics have been prescribed to treat fibromyalgia for many years and work by restoring chemical imbalances in the brain and help induce sleep. They're also used to treat panic attacks, post-traumatic stress disorder, and obsessive-compulsive disorder. Drugs in this category include amitriptyline (Elavil), clomipramine (Anafril), imipramine pamoate (Tofranil PM), desipramine (Norpramin), and nortriptyline (Aventyl). Many people can't tolerate tricyclics because of the high incidence of side effects, including dry mouth, constipation, and blurred vision.
Selective Serotonin Reuptake Inhibitors (SSRIs)
These medications have become increasingly popular in recent years. They work by blocking the removal (and deactivation) of serotonin. Selective serotonin reuptake inhibitors (SSRIs) are the most commonly used agents for treating depression because they have fewer side effects. Common SSRIs include fluoxetine (Prozac), paroxetine (Paxil), escitalopram (Lexapro), and sertraline (Zoloft). Side effects may include headache, insomnia, and sexual problems.
Mixed Reuptake Inhibitors
These antidepressants work by balancing the amounts of other neurotransmitters besides serotonin, such as dopamine and norepinephrine. Drugs in this category include venlofaxine (Effexor), buproprion (Wellbutrin), and duloxetine (Cymbalta). Because these medications have relatively few side effects and are potent inhibitors of spinal cord pain transmission, they are among the most commonly used medications in patients with chronic pain, including fibromyalgia.
Monoamine Oxidase Inhibitors (MAOIs)
This older class of antidepressant is not commonly used for fibromyalgia and is often a treatment of last resort for depression. If ingested with certain cheeses, wines, and pickles, or medications such as decongestants, monoamine oxidase inhibitors (MAOIs) can trigger dangerously high blood pressure that leads to a stroke. Medications in this category are isoarboxazid (Marplan), phenelzine (Nardil), and tranylcyproine (Parnate). MAOIs should never be taken with other antidepressants.
All antidepressants are required by law to carry a warning about increased risk for suicidal thoughts and behaviors in both children and adults. You may also become more hostile and agitated. If you do take an antidepressant, do so under your doctor's close supervision, and report any unusual thoughts or behaviors immediately.
Analgesics are painkillers that relieve the throbbing, aching, burning, and stabbing sensations that come with fibromyalgia. They come in two basic types that vary greatly in their strength. For people who have fibromyalgia, non-narcotic analgesics can sometimes relieve mild pain. Among the most popular is acetaminophen, which is found in over 600 over-the counter medications, including cough and cold products and sinus remedies. Too much acetaminophen can damage the liver, and the toxic dose for many people is only 50 percent higher than the highest recommended dose. So be careful not to take too much, and be on the lookout for medications that already contains acetaminophen. For instance, combining a cold remedy with acetaminophen for a headache can be dangerous if the cold medicine already contains acetaminophen.
Another option is nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen, and ketoprofen. These drugs work by inhibiting substances called prostaglandins, which play a role in pain and inflammation.
For a long time, aspirin was the only NSAID available. But the debut of indomethacin in the 1950s and the subsequent NSAIDs that followed gave patients more choices and were often less irritating to the stomach. Still, these medications are not benign. Every year, many people die from intestinal bleeding due to these drugs. Today, there are twenty types of NSAIDs available, both over the counter and in stronger prescription forms. Although inflammation is not usually present in people with fibromyalgia — unless they have arthritis — NSAIDs can relieve muscle aches, headaches, and menstrual cramps often caused by fibromyalgia.
You might think of narcotics as illegal street drugs, such as heroin, but there are also legal narcotics that provide pain relief. These drugs are also known as opioid analgesics, and are derived from the poppy plant. Narcotics work by acting on the central nervous system and interfering with the receptors that transmit pain.
Although frequently cited as a pain treatment, there is little evidence that the chronic use of these medications improve quality of life for fibro patients. In addition, narcotics can cause addiction and/or dependence. Many people also struggle with side effects, which include dizziness, nausea, constipation, and fatigue. Drugs in this category include hydrocodone with acetaminophen (Vicodin), tramadol (Ultram), propoxyphene (Darvocet), and oxycodone (OxyContin). As a result, narcotics are generally regarded as the choice of last resort for pain relief in fibromyalgia.
It's not unusual for people who have fibromyalgia to feel anxious about life. They may be uneasy about performing simple tasks like cooking a meal, fretful about their shaky memories, and nervous about doing their jobs. For some people, these concerns go beyond typical day-to-day issues and become a major disruption, causing what is known as generalized anxiety disorder, or GAD. For people who have anxiety, benzodiazepines might be a treatment option. These medications help relax tense muscles and induce sleep, and have both antianxiety and mild antidepressant qualities.
For people who have restless legs syndrome, a drug in this category called clonazepam (Klonopin) can sometimes provide relief from the nighttime restlessness that disrupts sleep. Other drugs in this category include alprazolam (Xanax) and cyclobenzaprine (Flexeril).
Take benzodiazepines carefully. These medications can cause addiction and depression. They may also affect memory and cognitive function and interfere with the stress response in the HPA axis. If you decide to stop taking them, do so slowly and under your doctor's supervision. Quitting abruptly can sometimes cause a withdrawal syndrome that produces symptoms such as heart tremors and palpitations.
Also, it's important to note that SSRIs and mixed reuptake antidepressants are very effective for long-term treatment of anxiety, as is the nonbenzodiazepine buspirone (Buspar).
Tense muscles frequently make the symptoms of fibromyalgia even worse by exacerbating your pain and making it hard to sleep at night. That's why some doctors may prescribe muscle relaxants, usually on a temporary basis. Unfortunately, they're not very effective at relaxing muscles in people with FMS.
Muscle relaxants act on the central nervous system. Some people may feel drowsy, dizzy, confused, lightheaded, or less alert when taking these drugs. The drugs may also cause blurred vision, clumsiness, or unsteadiness. Because of their sedating properties, these meds are occasionally used as sleeping agents, but in some people, they may cause insomnia. Drugs in this category include cyclobenzaprine (Flexeril), orphenadrine (Norflex), and carisoprodol (Soma). Some muscle relaxants, such as tizinidine (Zanaflex) and baclofen (Lioresal), also relieve muscle spasms.
It's best to stay off the road the first time you take a medication. Some drugs can cause excessive drowsiness that can make driving a serious hazard. So try to time the medication to a period when you're going to be home, where you can safely monitor side effects.
These medications are generally used to treat epilepsy and neuropathic pain — pain caused by irritation of the nerves themselves — and can also relieve pain in fibromyalgia sufferers. They work by reducing irritability of the nerve cell membrane, including that of pain nerves. They're especially effective when the pain is a burning sensation. Medicines in this category include gabapentin (Neurontin), pregabalin (Lyrica), and divalproex (Depakote). Besides relieving pain, these drugs can also improve sleep and symptoms of depression. Side effects include dizziness, drowsiness, and blurred vision.
Some people have found relief with over-the-counter creams that contain capsaicin, the same substance in a hot chili pepper, or sport creams, which contain aspirin derivatives that stimulate the skin and help block pain. One prescription topical that is generating a lot of interest contains lidocaine, a numbing agent. Although originally touted as ointments for arthritis, these creams have been found to provide temporary relief for FMS sufferers.
Getting a shot of anesthetic can sometimes provide temporary relief from fibro pain, especially if the pain is localized. Most of these injections use 1 to 2 percent lidocaine, a local anesthesia.
In recent years, some patients have had success with injections of Botox, the same botulinum toxin that has been used to eliminate wrinkles in aging skin. In small quantities, Botox works by paralyzing the muscles that are causing the painful spasms. Relief from a Botox injection can last up to three or four months, by some accounts. If you do decide to try injections, make sure to find a skilled practitioner who can do them safely.