Note: The autonomic nervous system (ANS) maintains the “automatic” bodily functions performed by many organs, muscles and glands, and drives responses to physical or emotional stress (fight or flight). This article is excerpted with kind permission from Chapter 25 of Fibromyalgia: Up Close & Personal by Mark Pellegrino, MD.*
Our autonomics have gone astray in fibromyalgia. In addition to causing pain and fatigue, the dysfunctional and hypersensitive autonomic nerves can cause a number of distinct conditions which are part of fibromyalgia but may require separate treatment approaches to try and calm them down.
In this chapter, I will address six such conditions that are the result of those dysfunctional autonomics:
- Irritable bowel syndrome,
- Irritable bladder,
- Anxiety disorder and panic attacks,
- Migraine headaches,
- And near-syncope [orthostatic intolerance].
IRRITABLE BOWEL SYNDROME (IBS)
IBS is seen in the majority of patients with fibromyalgia syndrome and can cause cramping, bloating, gas pains, diarrhea and constipation due to dysfunctional autonomic nerves.
Shortly after a meal, cramping and diarrhea may result. If the bowel is stretched from gas or constipation, there can be increased pain. There is no actual damage to the bowel, but the syndrome produces distressing symptoms. In addition to the cramping pain and diarrhea alternating with constipation, other symptoms can include swollen or bloated abdomen, mucus in the stool, or a feeling that you have not emptied your bowels completely after a bowel movement.
Certain foods can trigger IBS symptoms, including nut products, chocolate, caffeine, carbonated drinks, fatty foods and alcohol. Women with IBS will tend to have more symptoms during their menstrual period. And intestinal Candidiasis [yeast overgrowth] can aggravate IBS.
Different tests may be ordered to investigate IBS.
Tests that can be done include:
- Lab tests to evaluate liver and pancreas;
- Abdominal ultrasound to evaluate gallbladder and liver; and
- Barium enema to lower gastrointestinal tract; or
- Endoscopy to look inside the bowel and check for problems.
Usually these tests are normal with IBS, as the problem with IBS is not a structural problem but more of a functional problem with the autonomic nerves. There is no cure for IBS, but if it becomes a problem of its own, different things can be done to relieve symptoms.
Treatments include the following.
Avoid Foods That Make IBS Worse
Specific foods may be identified as causing IBS flare-ups. French fries, ice cream, chocolate, alcohol, soda and caffeine are examples of foods that can make IBS worse.
Some foods tend to make IBS better, such as foods that contain fiber. Fiber is found in whole grain breads, cereal, fruits, beans, vegetables and bran. If you are adding fiber to your diet, add a little at a time to let your body get used to it. Too much fiber all at once may aggravate IBS symptoms.
Alter Your Eating Style
Large meals can trigger IBS symptoms. Try eating four or five small meals a day or if you have your usual three meals, eat less at each meal.
The following medicines can be prescribed to help IBS symptoms.
- Fiber supplements: examples include Metamucil, Citrucel, Flax Seed
- Laxatives: these can help treat constipation. Examples include Senokot and Ex-Lax
- Antispasmodics: this type of medicine helps slow contractions of the bowel and can help decrease cramping, pain and diarrhea. Examples include Bentyl, Levbid, and Levsin
- Antidepressants: this class of medicine including tricyclics and serotonin reuptake inhibitors can help reduce pain and cramping.
Stress doesn’t cause IBS but once one has it, stress can aggravate the symptoms. Whatever the techniques you are using for your fibromyalgia, you can use these stress relieving techniques for IBS as well.
Irritable bladder is a sister of IBS. Sometimes it is called Interstitial Cystitis. The symptoms of irritable bladder include an urgent need to urinate frequently day and night, feelings of pressure, pain and tenderness around the bladder and pelvis, and decreased bladder capacity. Irritable bladder can also cause painful sexual intercourse in women especially, and in men there can be discomfort or pain in the penis. In most women symptoms can worsen around the menstrual cycle as with IBS.
Your doctor may need to rule out other conditions before considering a diagnosis of irritable bladder. A urinalysis and urine culture are frequently done to identify if any urinary tract infection is present. In men, prostate secretions may be cultured to rule out prostatitis. Cytoscopy is a test where a doctor uses a special instrument to look inside the bladder. Any suspicious tissue noted in the bladder or urethra may be biopsied to rule out cancer.
Treatments for Irritable Bladder Include:
Medications to reduce urgency. Specific prescribed medicines to reduce bladder spasms and urgency include Imipramine (Tofranil), a tricyclics antidepressant; Ditropan; Detrol; and Urimax.
Bladder distension. Some patients may benefit from bladder distension, a procedure which increases bladder capacity. The bladder, after distension, decreases the number of pain signals transmitted so symptoms lessen. In women, urethral dilation may also be effective.
Biofeedback. Women can learn to strengthen pelvic muscles to better control the bladder and increase blood flow to the bladder through biofeedback techniques. These techniques can be effective in treating severe irritable bladder symptoms.
As part of a biofeedback program, bladder training can be done. Basically the patient is taught to void at designated times and to use relaxation techniques and distraction to help keep on a voiding schedule. Gradually the patient tries to lengthen the time between the scheduled voids and hopefully the end result is to decrease the number of voids during the day and night.
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Depression is seen in over half of the people with fibromyalgia, and it can be serious and disabling. Low serotonin is found in those with depression, just as low serotonin is found in fibromyalgia, so it’s no surprise that depression and fibromyalgia are often seen together. Sometimes the depression requires its own separate treatment in addition to treating fibromyalgia.
Being depressed is a normal reaction to life’s stresses, but sometimes the depressed feelings take on a more sustained nature and lead to clinical depression that requires treatment. Symptoms of depression include: sadness, fatigue and loss of energy, feelings of hopelessness or worthlessness, lack of enjoyment from things that were once pleasurable, difficulty concentrating and making decisions, increased need for sleep or difficulty sleeping, decreased sex drive and sexual problems, a change of appetite causing weight loss or gain, and thoughts of death or suicide and even suicide attempts.
If I suspect depression, I will usually refer the patient to a depression specialist (psychiatrist) for treatment. The most common treatment for depression includes a combination of antidepressant medicines and psychotherapy. Psychotherapy is performed by a licensed mental health professional to focus on understanding and identifying the problems that are contributing to depression and how to regain a sense of control and happiness.
Medicines commonly prescribed for depression include tricyclics antidepressants and selective serotonin reuptake inhibitors, or a combination of medicines.
ANXIETY DISORDER AND PANIC ATTACKS
Everyone experiences anxiety throughout the day, but those with an anxiety disorder have much more than normal anxiety. Plus, the anxiety is chronic and unprovoked, and persons who have this are always in fear of impending disaster and worry excessively about health, money, work and family.
Since fibromyalgia causes dysfunctional autonomic nerves, it’s not surprising that chronic anxiety symptoms are present.
People with generalized anxiety have a difficult time relaxing and have trouble falling asleep, or their fibromyalgia-related sleep disorders are aggravated. Physical symptoms can develop including tremors, twitching, increased spasms, headache, irritability, sweating, hot flashes, lightheadedness, dizziness, and shortness of breath. Sometimes people feel nauseated. They may feel like they have a hard time swallowing or feel a lump in their throat.
People with panic disorder experience frequent and unprovoked panic attacks that involve a lot of anxiety symptoms such as: rapid heart beat, chest pains, fear of dying, flushes and chills, dizziness and lightheadedness, tingling and numbness, difficulty breathing.
Many patients with fibromyalgia have anxiety disorders and panic disorders that blend together to cause significantly bothersome symptoms. These may require separate treatments in addition to the fibromyalgia treatments. Treatments include psychotherapy and medications. Part of the psychotherapy and behavioral approaches include anxiety-reducing techniques involving breathing exercises, relaxation strategies, refocusing strategies and other measures.
Prescription medicines can help, and two categories of medicines that are used to treat anxiety and panic disorders are antidepressants (tricyclics antidepressants and selective serotonin reuptake inhibitors) and benzodiazepines (e.g., Ativan, Xanax, Klonopin, and Valium).
NEAR SYNCOPE [ORTHOSTATIC HYPOTENSION/INTOLERANCE]
People with fibromyalgia often have problems maintaining blood pressure in an upright position. Near-syncope is the result of the dysfunctional autonomic nerves that cause fluctuations in our blood pressure, especially when we go from a sitting to a standing position. People with near-syncope and fibromyalgia do not have loss of consciousness (true syncope), but we get a lightheaded feelings as if we are about to faint but we don’t actually faint. We have unsteadiness – a feeling of weakness or fuzziness without loss of consciousness. This is often synonymous with orthostatic hypotension or orthostatic intolerance.
With orthostatic intolerance, the blood pressure drops when we change positions because we with fibromyalgia tend to overshoot nerve responses to the blood vessels when we change positions. Thus, we are more at risk for fluctuations in our blood pressure, particularly a drop in our blood pressure, when we change positions.
Increased stress and certain medications including muscle relaxants, antidepressants and migraine medicines make us more at risk (on top of the risk we have with fibromyalgia). Evaluation of near-syncope can include checking blood pressure and pulse in the standing and lying down positions and examining the heart. An EKG, cardiac stress test, and tilt table testing may need to be considered.
The tilt table test is one of the ways to confirm orthostatic hypotension and document dysfunctional autonomic nerves as the cause of near-syncope in fibromyalgia. This testing was described in detail in Chapter 6 and can indicate neurally-mediated hypotension.
Treatment of near-syncope includes the following:
1. Drink extra fluids. Many times we are subclinically dehydrated, meaning we haven’t been drinking enough fluids each day. If we do not have enough blood volume we are more at risk for a drop in our blood pressure and thus more at risk for near-syncope. I recommend 64 ounces of water a day.
2. Increase salt intake. Sodium helps maintain our blood pressure and thus helps prevent decreased blood pressure in near-syncope. Many people are so concerned about salt intake because they think it is bad that many times they don’t take in enough salt. Too much of anything can be bad including too much salt, but if we are bothered by near-syncope it is recommended that we be more liberal with our salt because extra salt will help keep our blood volume up and decrease risk of hypotension or near-syncope. A trial of 2-6 grams of extra salt a day may help.
3. Prescribed special diuretic. Florinef (fludrocortisone) can be prescribed in severe cases of near-syncope. This is a salt-retaining diuretic that acts to increase blood volume and hold up our blood pressure.
4. Beta blockers such as Metoprolol. It may seem like a paradox to treat someone with low blood pressure with a blood pressure medicine. Beta blockers block beta nerve signals from the autonomic nerves. If someone has hypertension, blocking the beta nerves can help reduce blood pressure. However, these beta nerves are thought to play a major role in causing the low blood pressure in near-syncope, so blocking these beta nerves with a beta blocker can help reduce near-syncope episodes by stabilizing the blood pressure.
5. Compression garments. Tight-fitting leg garments or stockings (e.g., thigh-high TED hose, or Jobst stockings) can help minimize orthostatic blood pressure changes by decreasing the amount of “pooled” blood in the legs. Gravity forces tend to pull the blood into the legs more when standing, increasing the risk of an orthostatic drop in blood pressure. The stockings “press” the blood from the legs and keep it in the body’s trunk, the main blood “pool,” to help maintain the blood pressure.
6. Posture change strategies. Often times it is the sudden change from sitting to standing that triggers the autonomic-mediated drop in blood pressure (near-syncope). A treatment strategy is to eliminate any sudden changes in posture. This means gradually changing positions. For example, when first getting out of bed in the morning, one should sit in bed for 15-30 seconds first, then swing the legs over the edge of the bed and sit there fro 15-30 seconds, then plant the feet on the floor and stand up slowly but stay next to the bed for 15-30 seconds, then start walking. This gradual step-wise process can help eliminate near-syncopal episodes.
Migraine headaches are a common disorder in those with fibromyalgia. Many migraine sufferers have typical warning symptoms (auras) before the headache begins. Typical auras can last for a few minutes and include: bright spots or blurring of vision, increasing neck pain radiating up the back of the head, a feeling of increased anxiety or pressure, a tingling or numbness feeling.
Migraine headaches are caused by autonomic nerves causing excessive dilation of blood vessels in the head. The pain is not coming from the brain; rather, the pain arises from blood vessels, muscles and meninges (membranes that cover the brain) that are stretched, tensed or hypersensitized, causing the nerves to signal more pain.
Many people with fibromyalgia have different types of headaches, including migraine headaches, tension headaches and sinus headaches. If the headaches are severe enough, there may be a diagnostic work-up that includes a head CT scan, brain MRI, or an EEG to evaluate for any other types of pathology. Typically all these tests are normal for migraine headaches. A number of factors trigger migraine headaches, including:
- Foods such as cheese, chocolate, and others. People with food allergies can have frequent migraines as well
- Alcohol, especially red wine
- MSG (monosodium glutamate) – a common ingredient in Chinese food
- Withdrawal from caffeine or other drugs which constrict blood vessels
- Emotional changes and stressors
- Hormonal changes
- Increased fatigue
- Side effects from certain medications. It is common to have rebound headaches when taking pain medicines and migraine medicines, especially Ergotamine. Certain serotonin reuptake inhibitor medicines can also cause headaches as a side effect.
My Treatment Strategies for Migraine Headaches
Most fibromyalgia patients with migraine headaches actually have mixed type headaches. That is, they may have both migraine headaches and tension type headaches. The headaches are cervicogenic (arise from the neck). Painful neck muscles, ligaments and facet joints, common in fibromyalgia, can lead to tension headaches which “spill over” into migraine headaches. I want to treat all components of the headaches, i.e., treat the tension headache, but also try to treat the source of the headache – the neck.
1. Dietary modifications. If certain foods trigger migraine headaches, or food allergies exist, it’s best to avoid those foods altogether. Foods such as chocolate, beer, wine and cheese should be avoided if they are identified as migraine precipitators.
2. Decrease the pain. The patient who enters my office with a severe headache needs something that can provide immediate pain relief. Pain medicines (narcotic medications), central acting medications (such as Ultracet or Ultram, muscle relaxers, migraine medicines) can all be used. I don’t give patients every single medicine at once! The strategy is to decrease the headache that is present NOW.
Injection strategies are helpful for acute headaches whether they may be migraine or tension headaches. Trigger point injections to the upper cervical paraspinal muscles or suboccipital areas can help relieve migraine headaches. Trigger point injections to other neck muscles and trapezial muscles can help relieve neck and trapezial tender point areas that can be triggering the headaches.
Another type of injection called occipital blocks can be given to anesthetize the occipital nerve, a major contributing nerve to migraine headaches. The headache can disappear or decrease in intensity considerable following injections.
3. Decrease the frequency of migraine headaches. This strategy is a preventive one: reduce the frequency of migraine headaches or decrease the opportunity for migraine headaches to evolve from tension headaches. Several categories of medicines can be used including beta blockers, antidepressant medicines (tricyclics antidepressants and selective serotonin reuptake inhibitors), anti-seizure medicines such as Neurontin, Depakote and Keppra, as well as anti-spasticity medicines including Zanaflex.
The patient keeps a headache diary to determine if overall headaches have decreased over time. It is not realistic to completely eliminate headaches, but if someone who suffers from a couple of migraine headaches every week can reduce the frequency to one or two a month, this would be reported as a substantial improvement.
4. Rescue Medications. These medicines are designed to stop a headache that breaks through your preventive defenses. It’s great if you can reduce that number of headaches that occur, but if a headache does break through, it’s really great to have a medicine that stops it in its tracks.
The same medicines used in stopping the headaches described in #2 can be used as rescue medicines. The most common one used would be the migraine medications such as Midrin, Imitrex, Maxalt, Axert, Amerge and Zomig. I have had success with using Feverfew, 5-HTP and magnesium as natural products in patients who prefer to avoid prescription medicines or switch them around as necessary.
5. Physical medicine treatment. Trying to reduce the neck pain and spasms as part of the fibromyalgia will help in reducing the headaches. A therapy program can include modalities such as ultrasound, electric stimulation, specific hands-on manual therapy and instruction on stretches and exercises.
Just as everyone requires an individual approach to treating fibromyalgia, everyone also requires a unique treatment for his or her headaches. A combination of different strategies will usually work, and I try to help each patient find that right combination. I try to be Dr. Locksmith!
*Fibromyalgia: Up Close & Personal by Mark Pellegrino, MD, was published in 2005 by Anadem Publishing. ©Anadem Publishing, Inc. and Mark Pellegrino, MD, 2005, all rights reserved. This information-packed 424-page book may now be purchased in the ProHealth.com store.