Fibromyalgia: 2016 criteria and management

Fibromyalgia is the prototypical nociplastic pain condition, diagnosed by WPI and SSS thresholds with generalized pain for at least 3 months, even alongside another disease; exercise is the best-supported treatment.

1. Nociplastic pain explains the picture. IASP defines it as pain from altered nociception without clear tissue damage activating nociceptors and without a somatosensory lesion; augmented central processing is the proposed mechanism ¹.
2. Comorbid symptoms support the label. Proposed nociplastic criteria grade pain as "probable" when sleep disturbance, fatigue, cognitive problems or special-sense hypersensitivity accompany regional or widespread pain with evoked hypersensitivity ¹².
3. Two WPI/SSS routes meet the 2016 criteria. Either WPI of 7 or more with SSS of 5 or more, or WPI 4–6 with SSS of 9 or more, plus generalized pain in at least 4 of 5 regions and symptoms for at least 3 months ³.
4. Other diagnoses do not exclude fibromyalgia. The 2016 revision states the diagnosis is valid irrespective of other diagnoses, removing the earlier confusing exclusion recommendation ³.
5. Start with education and exercise. In the EULAR 2017 recommendations, exercise was the only "strong for" therapy; initial management is patient education with non-pharmacological care ⁴.
6. Then tailor further steps. For non-responders, EULAR suggests psychological therapy for mood or coping problems, drugs for severe pain or sleep disturbance, and multimodal rehabilitation for severe disability, all rated "weak for" ⁴.

Do not withhold the diagnosis because a patient has rheumatoid arthritis, lupus or another illness; coexisting disease does not rule out fibromyalgia under the 2016 criteria ³.

• The generalized pain criterion was added to stop misclassifying regional pain syndromes as fibromyalgia ³.
• The self-report version of the criteria is valid for research, not for diagnosing individual patients ³.
• The 2010/2011 criteria showed median sensitivity 86% and specificity 90% against 1990 and clinical criteria ³.
• Pregabalin for fibromyalgia: 300 mg/day in two divided doses within 1 week, maximum 450 mg/day ⁵.
• Milnacipran, an SNRI, is indicated for fibromyalgia, not for major depressive disorder ⁶.
• Milnacipran maintenance dose is halved to 50 mg/day at creatinine clearance 5–29 mL/min ⁶.
• "Possible" nociplastic pain needs chronic pain over 3 months plus evoked hypersensitivity in the painful region; "probable" adds comorbid symptoms ¹.
• EULAR notes that effect sizes for most fibromyalgia treatments are relatively modest ⁴.

• Applying the old "exclude other disorders first" rule ³.
• Using the 2010 lower WPI band (3–6); the 2016 band is 4–6 ¹³.
• Counting tender points; the 2010 criteria replaced tenderness with symptom severity ¹.
• Leading with drugs instead of education and exercise ⁴.