Fibromyalgia: Symptoms, Types, Causes and Treatment

Fibromyalgia is a complex and often misunderstood chronic pain condition that affects millions worldwide. While it has long been associated with widespread pain, we now recognize that this syndrome encompasses a broad range of symptoms and experiences. Recent research has improved our understanding of fibromyalgia, though its causes and optimal treatments remain the subject of ongoing investigation. In this article, we provide a comprehensive, evidence-based overview of fibromyalgia’s main symptoms, distinct types, underlying causes, and current treatment strategies.

Symptoms of Fibromyalgia

Fibromyalgia presents a diverse array of symptoms that go well beyond chronic pain. For many, these symptoms can disrupt daily life, making even simple tasks challenging. Understanding the multifaceted nature of fibromyalgia symptoms is essential for both patients and clinicians.

Symptom	Description	Prevalence/Impact	Source(s)
Pain	Widespread, multifocal, chronic	Core, affects quality of life	1 3 4 7
Fatigue	Persistent tiredness, low energy	Common, often severe	1 3 4
Sleep Problems	Nonrestorative, unrefreshing sleep	Nearly universal, worsens fatigue	1 3 4 7
Cognitive Issues	"Fibro fog": memory, attention deficits	Frequent, impairs daily functioning	1 3 4 10
Mood Disorders	Depression, anxiety, psychological distress	Highly prevalent, worsens outcomes	2 3 5 7
Somatic Symptoms	Headache, GI issues, paresthesia, stiffness	Variable, often present	3 4 8

Table 1: Key Symptoms

Chronic Widespread Pain

Pain is the hallmark of fibromyalgia. Unlike localized pain, fibromyalgia pain is typically described as widespread, affecting both sides of the body, above and below the waist, and often involving the axial skeleton (neck, back, chest, or abdomen). Patients may also report specific tender points—areas especially sensitive to pressure—though recent diagnostic criteria emphasize the overall pain experience rather than these points alone 1 3 4 7.

Fatigue and Sleep Disturbances

Persistent fatigue is another core symptom. Many patients feel exhausted even after a full night’s sleep due to nonrestorative or unrefreshing sleep. Insomnia, frequent nighttime awakenings, or feeling unrefreshed upon waking are nearly universal in fibromyalgia and can exacerbate pain and cognitive difficulties 1 3 4.

Cognitive and Mood Challenges

Cognitive symptoms—often termed “fibro fog”—include difficulties with memory, attention, and mental clarity. Mood disorders are also common, with depression and anxiety affecting a significant proportion of patients. These psychiatric symptoms not only worsen the subjective experience of pain but also lower overall quality of life 2 3 4 5 7 10.

Other Symptoms

Fibromyalgia is multisystemic. Other symptoms may include:

• Headaches or migraines
• Gastrointestinal disturbances (e.g., irritable bowel syndrome)
• Morning stiffness
• Paresthesia (numbness or tingling)
• Hypersensitivity to stimuli (light, sound, temperature)

The combination and severity of these symptoms can vary widely between individuals and even fluctuate over time 3 4 8.

Types of Fibromyalgia

While fibromyalgia is often considered a single syndrome, recent studies reveal significant heterogeneity. Identifying distinct subtypes can help tailor treatment and improve outcomes.

Type/Subgroup	Main Features	Clinical Relevance	Source(s)
High-Affectation	Severe symptoms, high psychological impact	Poorer prognosis, more distress	6
Low-Affectation	Milder symptoms, high self-efficacy	Better function, less impairment	6
Moderate/Intermediate	Moderate symptoms, varied coping	Variable course	6
Comorbid Psychiatric	Prominent mood/anxiety disorders	Lower pain threshold, worse QOL	2 3
Overlap Syndromes	With IBS, TMJD, CFS, etc.	Broader symptom spectrum	8 9

Table 2: Fibromyalgia Subtypes

Clinical Subgroups Based on Symptom Severity

Research suggests that fibromyalgia patients can be grouped by the severity of both physical and psychological symptoms:

• High-Affectation Group: These individuals experience both severe pain and significant psychological distress. They often have the highest levels of disability and impact on day-to-day life.
• Low-Affectation Group: Patients in this cluster have milder symptoms and higher self-efficacy in managing pain, leading to better functional outcomes.
• Moderate/Intermediate Group: This group falls in between, with moderate symptoms and varying degrees of pain coping strategies 6.

Psychiatric Comorbidity and Overlap Syndromes

A significant subset of fibromyalgia patients have prominent co-occurring psychiatric symptoms, particularly depression and anxiety. These comorbidities are associated with a lower pain threshold and worse overall quality of life 2 3.

Fibromyalgia also frequently overlaps with other central sensitivity syndromes, such as irritable bowel syndrome (IBS), temporomandibular joint disorder (TMJD), and chronic fatigue syndrome (CFS). These syndromes share underlying mechanisms and often complicate the clinical picture 8 9.

Why Subtypes Matter

Recognizing different fibromyalgia subtypes is crucial for:

• Personalizing Treatment: Tailoring therapy to specific symptom profiles and psychological needs.
• Prognosis: Understanding which patients are at higher risk for severe impairment.
• Research: Enabling more precise studies and improved understanding of underlying mechanisms 6.

Causes of Fibromyalgia

The cause of fibromyalgia remains complex and multifactorial, involving a blend of genetic, neurobiological, psychological, and environmental factors. No single cause has been identified, but advances in research have shed light on several key mechanisms.

Factor	Description	Evidence/Role	Source(s)
Genetics	Familial aggregation, genetic predisposition	Increases susceptibility	3 7 9
Central Sensitization	Altered CNS pain processing	Core mechanism, "volume turned up"	1 7 8 10
Neurotransmitters	Imbalances in serotonin, norepinephrine, glutamate	Augments pain perception	8 10 14
Stress/Trauma	Physical, emotional, or psychosocial	Often precedes onset, worsens symptoms	3 7 9 11
Infections	Viral/bacterial triggers (e.g., HCV, HIV, Lyme)	Possible initiators in some cases	7 11
Endocrine/Autonomic	HPA axis, neuroendocrine dysfunction	May exacerbate pain and symptoms	5 7 9

Table 3: Fibromyalgia Causative Factors

Central Sensitization and Pain Amplification

Most evidence points to fibromyalgia as a disorder of central pain processing. The central nervous system (CNS)—including the brain and spinal cord—appears to amplify pain signals, lowering the threshold at which normal stimuli become painful (hyperalgesia) or even making non-painful stimuli hurt (allodynia) 1 7 8 10. This “volume control” malfunction results from abnormal functioning in both ascending and descending pain pathways 10 14.

Neurochemical and Neuroendocrine Factors

Research shows altered levels of neurotransmitters in the brains of fibromyalgia patients. Specifically:

• Decreased: Serotonin and norepinephrine (which inhibit pain)
• Increased: Glutamate and substance P (which promote pain)

The hypothalamic-pituitary-adrenal (HPA) axis, which regulates stress hormones, is often dysregulated in fibromyalgia, potentially contributing to increased pain sensitivity, fatigue, and mood symptoms 5 9 10 14.

Genetics and Familial Risk

Fibromyalgia tends to run in families, indicating a genetic predisposition. Studies have found greater rates of fibromyalgia and related conditions in first-degree relatives, suggesting shared genetic factors that influence pain processing and mood regulation 3 7 9.

Environmental Triggers: Stress, Trauma, and Infections

Onset of fibromyalgia is frequently linked to stressful life events, emotional trauma, or physical injuries. In some cases, infections such as hepatitis C, Lyme disease, or HIV may act as triggers. These external stressors can disrupt the nervous system, leading to persistent pain and other symptoms 3 7 9 11.

Psychological and Behavioral Factors

Depression, anxiety, and maladaptive pain coping strategies are common in fibromyalgia and may both contribute to and result from the syndrome. These factors can amplify pain, reduce pain tolerance, and worsen the overall burden of disease 2 3 5 7.

Treatment of Fibromyalgia

Managing fibromyalgia requires a comprehensive, multi-modal approach. There is no cure, but a combination of therapies can help improve symptoms and quality of life. Individualization and patient engagement are key.

Approach	Examples/Description	Evidence/Role	Source(s)
Education	Patient info, self-management	Foundation of care	1 3 4 12
Exercise	Aerobic, strength, flexibility	Strongest evidence, core intervention	1 3 12
Psychological	CBT, mindfulness, stress management	Reduces distress, improves coping	1 3 4 12
Pharmacologic	SNRIs, pregabalin, TCAs, SSRIs	Modest benefit for pain/sleep	1 3 12 14
Multimodal Rehab	Combined therapies, tailored plan	For severe disability	1 3 12
Other	Acupuncture, massage, cannabis	Variable evidence, adjunctive	13 14

Table 4: Key Treatment Strategies

Patient Education and Self-Management

Education is the cornerstone of fibromyalgia care. Empowering patients to understand their condition, set realistic goals, and actively participate in their treatment improves engagement and outcomes 1 3 4 12.

Exercise: The Strongest Evidence

Regular aerobic exercise—such as walking, swimming, or cycling—has the strongest evidence for improving pain, fatigue, and function in fibromyalgia. Programs should be tailored to individual abilities and started gradually to avoid flare-ups 1 3 12.

Psychological Therapies

Cognitive-behavioral therapy (CBT), mindfulness, and stress reduction strategies are effective for managing mood symptoms and helping patients develop healthier coping skills. These interventions can reduce catastrophic thinking, improve pain self-efficacy, and enhance quality of life 1 3 4 12.

Pharmacological Treatments

While medications are not a cure, certain drugs can help manage pain and sleep disturbances:

• SNRIs: Duloxetine, milnacipran—target central pain processing
• Alpha-2-delta ligands: Pregabalin—modulates pain signaling
• Tricyclic antidepressants (TCAs): Amitriptyline—improves sleep, reduces pain
• SSRIs: Less robust evidence, but may help mood 1 3 12 14

Combination pharmacotherapy may be considered, though evidence for its superiority is limited and side effects can be problematic 15.

Multimodal and Individualized Care

A stepwise, individualized approach works best, integrating education, exercise, psychological therapies, and medications as needed. For those with severe disability, multimodal rehabilitation programs that combine several interventions are recommended 1 3 12.

Adjunctive and Emerging Therapies

Massage, acupuncture, and medical cannabis are being explored as adjuncts. Evidence is mixed, but some patients report symptom relief, particularly for pain and sleep 13 14.

Conclusion

Fibromyalgia is a multifaceted condition that extends far beyond chronic pain. Understanding its diverse symptoms, subtypes, multifactorial causes, and the necessity for individualized, multi-modal treatment is essential for optimal patient care.

Key takeaways:

• Fibromyalgia symptoms include chronic pain, fatigue, sleep disturbances, cognitive issues, mood disorders, and various somatic complaints 1 2 3 4.
• There are distinct subtypes of fibromyalgia, reflecting differences in symptom severity, psychiatric comorbidity, and overlap with related syndromes 6 8 9.
• The causes of fibromyalgia are complex and involve central sensitization, genetic predisposition, neurochemical imbalances, stress, trauma, and, in some cases, infections 3 7 8 9 10 11.
• Treatment relies on a comprehensive, individualized plan combining education, exercise, psychological therapies, medications, and, when needed, multimodal rehabilitation 1 3 12 14.
• Patient engagement, shared decision-making, and ongoing support are vital to improving quality of life for those living with fibromyalgia.

Fibromyalgia remains a challenging disorder, but with increased understanding and compassionate, evidence-based care, meaningful improvement is possible.