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Prescribed Medications for Fibromyalgia: By Mark Pellegrino, M.D. – 2007 Update

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Mark J. Pellegrino, M.D., is Board Certified in Physical Medicine and Rehabilitation and Electrodiagnostic Medicine, and is one of the nation’s leading experts on Fibromyalgia. Dr. Pellegrino is the author of numerous books and articles on Fbromyalgia, and despite having Fibromyalgia, he maintains an active medical practice with more than 20,000 patients cared for. He was recently named in “Best Doctors in America.” The following article is an updated excerpt from a chapter of Fibromyalgia, Up Close and Personal by Mark J. Pellegrino, M.D.*

Prescribed medicines are an important part of fibromyalgia treatment. Presently there are no FDA approved medicines for the treatment of fibromyalgia. Many studies have been published, however, that show how numerous prescribed medicines can benefit those with fibromyalgia. Physicians are able to prescribe these medicines off-label for fibromyalgia because of these evidence-based studies.

Pain relief, improved sleep, more energy, and better mood are examples of goals that prescription medicines can help you reach. People with fibromyalgia tend to be more sensitive to medications and often experience side effects such as nausea, drowsiness, or lightheadedness. Lower doses of medicines need to be considered for fibromyalgia. Prescribed medicines can provide great benefits to many, so it is worthwhile to work together with the physician to try to find a successful medicine regimen.

Categories of drugs used in the treatment of fibromyalgia can include:

1. Analgesics

2. Anti-inflammatory medicines

3. Antidepressant medicines

4. Muscle relaxants

5. Sleep modifiers

6. Anti-anxiety medicines

7. Other medicines used to treat chronic pain.

1. Analgesics

Analgesics are pain killers and can include over-the-counter medicines such as aspirin and acetaminophen, or prescription-strength pain pills like narcotics (opioids) – ie codeine, hydrocodone, oxycodone, morphine and fentanyl. Tramadol (UltramTM) is a pain reliever that differs from narcotics in its action on the central nervous system.

These medications do not alter the fibromyalgia, but they can help take the edge off of pain by blocking the central pain pathways. Narcotic medications have potential for adverse side effects including drowsiness, difficulty with concentrating, and addiction, so they should be used carefully.

Many people with fibromyalgia are sensitive to codeine medicines, which can cause nausea or an allergic reaction. Tramadol can cause allergic reactions in people sensitive to codeine, and a small number of people taking tramadol have seizures. As a pain specialist, I will frequently prescribe analgesics, including narcotics, for patients experiencing severe pain.

You and your pain physician may sign a written agreement when using scheduled medicines for pain, such as opioids.

2. Anti-Inflammatory Medicines

Anti-inflammatory medicines include aspirin, nonsteroidal anti-inflammatories (NSAIDs) such as ibuprofen, naproxyn, etodolac, nabumatone, and the Cox-II inhibitors (i.e., CelebrexTM), and corticosteroids such as prednisone or dexamethasone. These medications are both anti-inflammatory and analgesic.

Some of these medicines, such as ibuprofen, are available both over the counter and by prescription. Because fibromyalgia is not a true inflammation, these drugs may be less effective in reducing pain. However, these drugs can be helpful in reducing pain that flares up with excessive physical activity, tendinitis, or bursitis, and should be used only as needed.

n If the NSAIDs are helpful for overall fibromyalgia pain, they can be continued on a regular basis as long as there are no major side effects.

n The major side effect of the anti-inflammatories is bleeding from gastrointestinal ulcers. This problem is more common the longer the medicine is taken.

n The Cox-II inhibitors (Celebrex) have much fewer side effects to the stomach lining and the kidneys.

n Injectable anti-inflammatories can be considered; these avoid the stomach altogether by getting absorbed intra-muscularly.

I prescribe various types of anti-inflammatories on a regular basis. To avoid risk of bleeding or other side effects, patients must not take over-the-counter anti-inflammatory medicines if they are already taking them by prescription. Sometimes a medicine to protect the stomach lining (called proton pump inhibitors) is recommended along with the anti-inflammatory medicines. [These medicines “inhibit” gastric acid production.]

3. Antidepressant Medicines

The antidepressant medicines include tricyclics (for example, amitriptyline, nortriptyline, doxepin, and trazodone), selective serotonin reuptake inhibitors (ProzacTM, ZoloftTM, PaxilTM, EffexorTM, and CelexaTM), and the selective serotonin and norepinephrine dual reuptake inhibitor (CymbaltaTM). These medicines can treat pain and improve sleep and mood disturbances seen in fibromyalgia. The tricyclic medicines can be effective, but frequent side effects include dry mouth and drowsiness. Using lower doses may decrease side effects.

Because of the extreme sedation and morning hangover effect common with amitriptyline, I’ve found that nortriptyline or trazodone has fewer side effects but gives the same benefit. Even though the sedation side effect of the tricyclic medicine may have worn off by morning, the other benefits of the drugs (decreased pain, muscle relaxation, and improved mood) can continue throughout the day. Because the tricyclic can provide more than one beneficial effect, I think these medicines are handy in fibromyalgia treatment.

The selective reuptake inhibitors work well in treating depression. They also block the breakdown of serotonin, the brain hormone that is low in persons with fibromyalgia and depression. Serotonin is important in the brain’s regulation of pain and sleep. By selectively inhibiting the breakdown of serotonin, these medicines increase the serotonin concentration in the body and its beneficial side effects. These medicines have fewer side effects than the tricyclics, although they can cause sexual dysfunction and weight gain.

Cymbalta is a dual acting antidepressant medicine that has been found to decrease pain in patients with fibromyalgia. It also helps improve energy, decrease anxiety, improve depression, and help alertness and concentration – so this medicine has multiple potential benefits in fibromyalgia. It has been found to help those with fibromyalgia who are not clinically depressed. I have found this medicine to work very well for many of my patients. It is well tolerated. Sometimes there is some nausea and lightheadedness when the medicine is first started, but using a low dose to start reduces the side effects.

Sometimes using a combination of a reuptake inhibitor during the day and a tricyclic at nighttime can be an effective combination medicinal approach. Your physician can help determine what is best for you.

4. Muscle Relaxants

Muscle relaxants can decrease pain in people with fibromyalgia. Medicines in this family include FlexerilTM, SomaTM, SkelaxinTM, and RobaxinTM. The most common side effect is drowsiness, although Soma and Skelaxin cause less of it.

I have found that muscle relaxants do not really decrease muscle spasms or truly “relax” muscles, because the painful area still has palpable spasms. Rather, the medicine appears to help by a central neurological mechanism that reduces muscle pain. If drowsiness is a side effect, this medicine should only be taken in the evening so it doesn’t interfere with driving or concentration. Flexeril is a popular medicine for evening. Although it is a muscle relaxant, it is very similar to amitriptyline in structure and effect, hence the benefits reported.

Medicines in the antispasticity category can be used to treat muscle spasms. Two of these medicines, ZanaflexTM and BaclofenTM, have been shown to help reduce back muscle spasms and pain. Antispasticity medicines are primarily intended for people who have neurologic conditions causing involuntary muscle spasms (such as spinal cord injuries, multiple sclerosis, or strokes). However, they can help patients with fibromyalgia too.

5. Sleep Modifiers

Various medicines can treat insomnia. Medicines already mentioned above can help improve sleep even though they are not classic “sleeping medicines.” Analgesics can help sleep by decreasing the pain that interferes with sleep. Some antidepressants and muscle relaxants can help sleep by causing drowsiness and deeper sleep. Anti-anxiety medicines such as AtivanTM or KlonopinTM can relax the mind and allow better sleep.

True sleep modifiers include benzodiazepines like RestorilTM and the hypnotic non-benzodiazepines such as AmbienTM. The most common reported concern about using sleep modifiers, especially benzodiazepams, is the habit-forming potential. Ambien is reported to be less habit-forming but can cause “rebound insomnia” when it’s stopped. LunestaTM is a newer sleep modifier that is not habit forming and doesn’t cause rebound insomnia. It can cause a metallic taste in the mouth or headaches, but is usually helpful in those patients who tolerate it.

I have found that sleep modifiers improve deep sleep, and particularly improve the morning perception of a good night’s sleep. This improved sleep can carry over into a better day.

Sleep modifiers are short-acting medicines, so they work during the night and are usually eliminated from the body by morning, hence the low chance of a morning hangover. Some people report nightmares with these medicines, but usually these medicines are “silent,” that is, one doesn’t realize any medicine was taken, other than knowing that sleep was better.

6. Anti-Anxiety Medicines

Anxiety is a common problem in fibromyalgia and contributes to pain, muscle tension, and irritability. It can make depression and insomnia worse. Various medicines including antidepressants and muscle relaxants treat anxiety. Benzodiazepines such as Klonopin, Ativan, and XanaxTM, are commonly used medicines. These medicines also cause sedation and thus can improve sleep. Possible side effects include depression and decreased memory. Sometimes it is hard to determine whether symptoms are due to fibromyalgia or are side effects of medication.

I have found Klonopin to be a particularly useful medicine in the evening, especially when there are leg symptoms (pain, restless leg syndrome, jerking of the legs called myoclonus) that interfere with sleep. Low dose Klonopin therapy is one way to improve the balance of the inhibitory receptors (GABA) and the excitatory receptors (NMDA) in the central nervous system.

Most fibromyalgia patients have too much activity in the excitatory receptors (NMDA receptors), and Klonopin can increase the pain inhibitors’ activity to achieve a more normal balance, improving sleep and reducing pain.

7. Anticonvulsant Medicines

This class of medicine includes NeurontinTM (gabapentin) and LyricaTM (pregabalin). Neurontin is an example of a medicine originally used to treat seizure disorders (an anticonvulsant or antiseizure medicine). It was later found to be helpful in treating pain, particularly neuropathic pain. Many people with fibromyalgia who have a lot of burning or electric shock feelings in their hands and feet have improved with a trial of Neurontin.

Lyrica, the “next generation” of Neurontin, was found to be more selective in blocking neuropathic pain and had fewer side effects. Studies have shown it benefits many with Fibromyalgia, so it is a commonly prescribed medicine for this condition.

Other Medicines Used to Treat Chronic Pain

Other medicines can be used to treat pain. Headaches are a common problem with fibromyalgia, and various headache medicines are available. In addition to the medicines described above, headache medicines include ergot alkaloids, sumatriptan, calcium channel blockers, and beta blockers.

Over-the-counter (OTC) products are available as well. In addition to the aspirin, acetaminophen and anti-inflammatory options (ibuprofen, naproxyn), two other OTC products are worth mentioning that may help in fibromyalgia. One is guaifenesin, a mucolytic (mucous dissolving) substance used for congestion. This has been found to support reduced muscle pain in some with fibromyalgia, presumably by acting to support muscle detoxification and excretion of phosphates from the muscles.

Dextromethorphan, the OTC cough suppressant medicine, has also been found to help pain in some with fibromyalgia. This medicine can block pain signals at the spinal cord level. Check with your doctor about any OTC medicines that may be helpful.

Treatment Strategies

In addition to the variety of medicines available for fibromyalgia treatment, a variety of doctor “strategies” are also available. Doctors who prescribe medicine will usually find – through trial and error – an effective and favorite strategy. There is no single right way to prescribe medicines for fibromyalgia, and more than one strategy may work for different people and different doctors. Over the years, I have discovered basic strategies that seem to work best for me when using prescription medicines, and I try to teach my patients some basic medicine goals:

n Understand there is no magical pill that will get rid of all fibromyalgia symptoms.

n Experiment with your doctor to determine which medicines can help “control” your symptoms.

n Responsibly use analgesics and narcotics to take the edge off the pain. These medications will not relieve all your pain but may improve symptoms and comfort.

n Educate yourself about expectations of medication.

n Use the lowest effective dose of medicine; wean off whenever possible (and discontinue any medication that is not working).

n Be flexible with medications. Keep it simple.


* This article is reprinted with permission from the author. It is excerpted from Fibromyalgia, Up Close and Personal, by Mark J. Pellegrino, M.D., Copyright 2005 Anadem Publishing, Inc.
(c) 2005 Mark J. Pellegrino, M.D., and Anadem Publishing, Inc. All Rights Reserved.

Note: This information has not been evaluated by the FDA. It is generic and for general information purposes only, and is not meant to prevent, diagnose, treat or cure any condition, illness, or disease. It is very important that you make no change in your healthcare plan or regimen without researching and discussing it in collaboration with your professional healthcare team.

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11 thoughts on “Prescribed Medications for Fibromyalgia: By Mark Pellegrino, M.D. – 2007 Update”

  1. dgmcjm says:

    Just finished the article. My daughter and I both have the condition. I was diagnosed in the late 1970s @ which time it was a “last ditch” diagnosis, thought to be “in your head”. At the same time I was being seen to rule out rheumatoid rthritis, being told by the MD that he felt sorry for my husband. I have definitely been diagnosed as having both the diseases. I take several of the medications listed for both problems as well as Remicade for the RA. Along with an altered life style to accomodate the many symptoms, I follow a low impact exercise program @ Curves. Without it, I would have very limited mobility and a wheelchair would be in the picture.
    Dr. Pellegrino diagnosed my daughter with severe “fibro”. She also follows a five day per week exercise program @ Curves and has totally discontinued the muscle relaxor she was taking three times daily. She is only 38 and leads a very active life that involves teen-agers and a full-time job.
    I was really reassured by the article that the meds currently prescribed for me as part of Dr. Pellegrino’s treatment plan.
    The fact that fibromyalgia is definitely a recognized diagnosis with an active support group also helps us cope with the many symptoms.

  2. havenofrest says:

    I have suffered with Fibromyalgia for 18 years and I have just been dignosed with Chronic Fatigue Syndome with COPD with Bronchritis, pnueima, plursis. I have tried to find some vitiams and supplements for this diease. I am on Neurton and Xanax and several more meds and if anyone of you have some ideas for vitiams or supplements let me know.

    1. GrandmaJoyce says:

      I have had (documentation) this all my life. I am 53. I use a lot of vitamins and minerals to keep a wellness balance. My V/M I won’t do without and have the blessings of my rheumy are a high dose of malic acid/magnesium combo and also high dose of Vit C, potassium, as well as guaifenesin. I do alot of others, but these are the first on the list to keep. Of the prescribed “meds” I only use Ibuprofen 600mg x 3 per day. I find the further I move from the mainline meds, the better I am at getting back to who I was and need to be. Some people with FMS can’t do that. I have been working with my treatment for almost 20 years–previous to that knowing something was going on, and using similar treatment.
      I am a swimmer, so my exercise program is highly additive–water, water, water. The more I swim, the more I can move more freely. This will make high pain days less severe, knowing just getting to a pool will help the pain and stiffness to move on. I started lap swimming about 3 1/2 years ago, 3 times a week. I am up to 380 miles.
      I have been an FMS/CFS patient who has been bedridden. Trying suggested medications made me even more tied to the bed–mentally and physically. Depression was great, as the understanding of FMS was limited and not printed, taught, as it is now.
      I was at my 35th class reunion and so many friends remember me as the kid who was always sick. Thing is, many of my classmates now have FMS as well in their adulthood.
      I feel as I have been an experiement most of my life, so I choose to be in control of my life. My medical people are my support group. They can recommend, I do research and then decide on what to take. The list is long. So, since 1997, I have been in total control of what I take. As I stated before, the better I keep my health in check by minerals/vitamins, the less apt to get sick, get the flu or colds. The less the FMS will act up–this is for me.
      My rheumy felt that I was enough in control of my life, to return me (after serveral years of seeing her) back to my GP/NP at my local clinic to keep me doing what I am doing.
      New meds for the regular things such as BP, diabetes, etc are a trial as not to skrew up what I am already doing. They must be researched my by pharmacist and doctor before I begin anything new. All side effects that even list 1% chance usually mean it will happen to me. By not being on top of things has meant months of side effects and terrible reactions resulting in $$ money, testings.
      I hope this has helped you. Grandma J.

    2. sknighthawk says:

      I have fibromyalgia and severe chronic fatigue syndrome, and I have suffered with these for 21 years. I have every symptom that could ever be mentioned, and I have been on an extensive gammet of drugs and therapies, not to mention the neverending list of doctors. I do use alternative medicine including acupuncture and herbs, but no insurance covers them and I cannot afford. Each time I see a new doctor, they try to get me on drugs I have already taken or ones I cannot tolerate. I have found my only relief for sleep deprivation is with Klonopin, but I do feel hungover, so I tend not to take it regularly. My fatigue is so severe, and I have begged doctors for help. I have friends on dexedrine that swear their lives are so back to normal, but none of my doctors will prescribe. I finally started on Provigil, and it has helped, but now it is not working so well and fatigue is overwhelming again. My pain is unrelenting, and now I am having shooting pains in my legs that feel like a railroad spike is being driven into the bones. I have been on Darvocet for 21 years, and it stopped working a long time ago. I have begged doctors for something that is more effective, and Vicoden is offered. Vicoden makes me violently ill, so they offer nothing else. I can handle Percocet some and Morphine helps alot. I was on Morphine before I moved where I live, but doctors here won’t prescribe. I began Tramadol this year, but have to take two with a Darvocet for only a little relief. Tramadol also makes me dizzy and nauseated. Doctors are so concerned about addiction when prescribing pain meds, but honestly, what does it matter when they have a patient that will be in pain for the rest of their lives? Klonopin and Darvocet are addictive, too, but I do not believe I am seriously addicted. Tizanidine works for muscles, but increases the fatigue. Lyrica doesn’t work. Cymbalta makes me so dizzy I can’t stand up, and relieves no pain at all. Neurontin works some, but fatigue is overwhelming. So, I would like to know why doctors will not prescribe medications that could work for me or at least try them on me. I have asked for B12 injections, but again, no. I am more frustrated with seeking treatment than with the disease.

    3. aimeesue78 says:



    4. cskmurray says:

      Read up on this combo. It’s helped me so much.

    5. pen101 says:

      My wife has suffered long enough!
      Gab, cymb, lyrica…no good…no good…no good!
      Almost cost us our marriage!
      Women care, they have always been the main stay in any family, when her child hurts, does Mother not feel?
      I believe FMS is caused by several factors, lifestyle, family, work, INJURY will finally do it…well it did for my wife. An “untreated reverse whiplash” made her succumb to this. Now after being big pharma’s cash cow, we are going for a more holistic approach inclusive of a low impact exercise regime.
      It has been long said, “if a hat drops in China, my wife will weep”, she’s just a sensitive caring person.
      We are looking at adding cal/mag/malic acid, 5-htp and getting of the delantin and amitrypaline gone…the lyrica does very little and has already weaned herself off, and has sice weaned off quite a bit of weight too!
      I look at my wife, I know what pain is, I see it in her eyes and the dark circles that surrounds them is almost unbearable.
      Chronic fatigue, has been creeping in, the pain from the injury, the IBS makes for a not so great life. NEVER MIND THE SEXUALITY THAT BOTH THE SNRI’S and FMS has robbed her of.
      “Oh gee…we really don’t know how to treat you so we will just cash cow you out at the cost of being human..” THIS MUST STOP…A new agenda must be set, instead of treating patients how about a cure of 52,167 conditions?

  3. uatraveler says:

    I am on the new prescription drug Lyrica and started at 50mg 2 times daily. I am now at 75mg 2x daily. The weight gain is definite and the tiredness during the early part of the day around 10-1:00. I have learned to know the symptoms. Like the article printed above I am also on Xanax as needed, Soma as needed (which is every day) mostly night time or a bad flare up, Amitriptiline (Elavil) at nights to help sleep. I have Vicodin for the flare ups, but I admit I hate taking those and will only do it if I am ready to go to the e.r. I also take Zitia, Pravachol, and Empareil for chol and high blood pressure. It took years and lots of bad, bad days to get control of my life again. The Lyrica is remarkable and I really don’t care if I gain 250lbs., if I am pain free for most of the days. Just recently I took Zicam over the counter for a bad cold and throat – do not do that – I lost all the results I had gained with the Lyrica, I feel it was associated to that set back. I am now back on track, and able to stretch and do some yoga, and meditation. I have a busy life, traveling with my husbands jobs, and we have 4 grandchildren and expecting our 5th. we have a huge house to clean and a fifth wheel travel trailer to load when we leave and unload when we return. We are really good grand parents and the kids (now) know – they can touch me, hug me, and I can actually pick them up. My husband sees I am in better spirits and back to my old self since 1995. There is a happy ending, if you give the meds a chance and time, they will work – expect the weight gain and the lunch time sleepiness – the trade off is worth it! Deborah Rizzo

  4. 57 says:

    i just read your post and my god you have been through hell. It is hard to understand why these doctors would give you all of these meds!!! your body must be in crisis . I have both of these fibro and etc for 19yrs but lucky for me I have had good doctors and not alot of drugs the cfs is awful I had it for quite a few years . what I can say to you is read Suzane sommers book Breakthrough and you will find alot of help it is a great read. Please if the doc won’t give you a med you beleive in look for a new doc some one that specializes in this disease . Do not give up hope , I hope you have a good support system a friend or family member and do not feel guilty if you sleep or can not do something it will all wait, take care , sherry weaver stay strong

  5. lucybythesea says:

    Thanks for this overview. Personally I have found a Calcium/Magnesium/Zinc supplement has helped the pain and unrefreshing sleep. Also meditation helps to get out of the fight-or-flight that inflames fibro. Just 10 mins a day helps the next day. I also take tramadol everyday, although it is not as effective as it used to be.
    Stay strong, my fellow-fibro warriors!

  6. Webmind says:

    This excellent article was written about 6 years ago? Would sure love to read a follow-up from this great doctor.

    Most doctors now will only prescribe FDA approved drugs, which are mostly junk for most people. Too bad the FDA has been bought out by the pharmaceutical companies and does what is in the best interest of profit, not health.

    A crime against humanity against the millions who are suffering.

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