Multiple pain in the whole body is a disease!

*It is only for medical professionals to read for reference.
The symptoms of fibromyalgia are diverse and must not be taken lightly! Fibromyalgia (FM), also known as fibromyalgia syndrome, is a common chronic diffuse pain syndrome caused by a malfunction of central nervous sensory afferent processing.
Its main symptoms include pain in multiple sites, severe fatigue, Stiffness, sleep disturbance, cognitive impairment, and psychological problems are characterized by heterogeneity of clinical manifestations and diversity of core symptoms
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The etiology and pathogenesis of FM may be related to central sensitization, neurotransmitter imbalance, neurological dysfunction, abnormal hypothalamic-pituitary-target gland axis, etc.
The risk factors include psychosocial factors, genetics, and gender (the proportion of women with FM is more High), obesity, age, common diseases include chronic tension headache, chronic migraine, irritable bowel syndrome, chronic low back pain, shoulder pain, rheumatoid arthritis, osteoarthritis, and diabetes
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The clinical manifestations of FM include pain and tenderness, various types of pain, common soreness, cold pain, cramping pain, etc.
The shoulder girdle, neck, back, hip and other parts are common.
Rest often does not relieve the pain.
Inappropriate activities and exercises can cause symptoms Exacerbation, fatigue, stress, mental stress, cold, rainy weather, etc.
can aggravate symptoms; sleep disorders manifest as difficulty falling asleep, light sleep, easy awakening, dreaminess, unrecoverable sleep, and lack of energy; neuropsychiatric symptoms manifest as emotions Depression, irritability, severe anxiety and depression, and difficulty concentrating, memory loss, impaired executive ability and other cognitive disorders; other accompanying symptoms such as dizziness, paroxysmal dizziness, numbness of limbs, soreness, tingling, sense of ants, pharynx foreign body sensation, poor tolerance upright
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FM treatment drugs are mainly calcium channel modulators (such as pregabalin), antidepressants, tramadol, muscle relaxants (such as cyclobenzaprine) and so on
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The "Chinese Expert Consensus on the Clinical Diagnosis and Treatment of Fibromyalgia" (2021) pointed out that pregabalin, 5-hydroxytryptamine (5-HT) and norepinephrine (NE) reuptake inhibitors (SNRIs), A Mitriptyline; second-line treatment recommends tramadol, cyclobenzaprine, and selective serotonin (5-HT) reuptake inhibitors (SSRIs)
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"Interpretation of the 2017 European Anti-Rheumatic Alliance Fibromyalgia Treatment Management Recommendations" (2018) pointed out that duloxetine, pregabalin, and tramadol can be used for severe pain
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Severe sleep disorders can choose low-dose amitriptyline, cyclobenzaprine, pregabalin (at night)
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Pain-related depression and anxiety can be treated with psychotherapy
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1 Calcium channel modulators such as pregabalin can reduce the excessive release of calcium ion-dependent excitatory neurotransmitters (such as glutamate and substance P) by binding to the α2δ subunits of voltage-gated calcium ion channels, thereby inhibiting hyperalgesia And central sensitization, and improve sleep and emotional disorders, while improving discharge-like pain or electric shock-like pain, burning pain, tearing pain, gunshot-like pain or acupuncture-like pain
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Pregabalin is analgesic and has good effects in reducing pain, improving sleep and quality of life
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Adverse reactions include dizziness, drowsiness, headache, nausea, edema, blurred vision, ataxia, skin rash, weight gain and so on
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It is contraindicated in people with severe heart failure
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2 Antidepressants such as SNRIs, tricyclic antidepressants (TCAs), SSRIs
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The "Guidelines for the Diagnosis and Treatment of Fibromyalgia Syndrome" (2011) pointed out that antidepressant drugs can significantly relieve pain, improve sleep, and adjust the overall state, but the effect of improving tenderness is not ideal
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5-HT and SNRIs, such as duloxetine and milnacipran, can inhibit the reuptake of 5-HT and NE, and can improve numbness, burning pain, swelling pain, etc.
, and can also improve mood and sleep
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Duloxetine can significantly improve the pain, tenderness, morning stiffness and depression symptoms of FM patients, and the effect can be maintained for a long time, but there is no significant improvement in fatigue, and the effect on sleep disorders is uncertain
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Adverse reactions are nausea, loss of appetite, dry mouth, constipation, sweating, anxiety, insomnia, drowsiness, fatigue, tremors, irritability, increased heart rate, elevated blood lipids, increase the risk of bleeding
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It is forbidden to use it in combination with monoamine oxidase inhibitors or serotonin enhancers, because central serotonin syndrome may occur
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Milnacipran can effectively improve the pain, fatigue and cognitive ability of FM patients, but it does not improve sleep
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Common adverse reactions include nausea, headache, constipation, dizziness, sweating, anxiety, fever, and dysuria
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Combination with monoamine oxidase inhibitors is forbidden.
Those who use monoamine oxidase inhibitors can use milnacipran at least 2 weeks apart.
If the use of milnacipran is changed to a monoamine oxidase inhibitor, an interval of 1 week is required
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TCAs-Amitriptyline (low dose) by blocking the reuptake of NE and 5-HT in the presynaptic membrane, blocking voltage-gated sodium channels and α receptors, regulating the downward pathway of pain transmission, and exerting analgesia At the same time, its metabolite nortriptyline can effectively enhance the activity of NE, so that low-dose amitriptyline has a good analgesic effect, can improve numbness, burning pain, falling pain, etc.
, and can also improve mood and sleep
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Amitriptyline has obvious anticholinergic effects, often accompanied by adverse reactions such as antihistamine and antiadrenergic
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The main adverse reactions include excessive sedation, cognitive dysfunction, abnormal gait and cardiotoxicity (sinus tachycardia, arrhythmia, increased ventricular ectopic beats, orthostatic hypotension, myocardial ischemia and even sudden cardiac death)
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Avoid using it if you are at risk of ischemic heart disease or sudden cardiac death
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The research of SSRIs in the treatment of FM is limited, and the results are inconsistent
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According to the "Chinese Expert Consensus on Clinical Diagnosis and Treatment of Fibromyalgia" (2021), studies have shown that fluoxetine, especially high doses (up to 80 mg), can improve pain, fatigue and depression, but citalopram, sertraline and par The clinical studies of Roxetine in the treatment of FM showed mixed results
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According to the "Guidelines for the Diagnosis and Treatment of Fibromyalgia Syndrome" (2011), SSRIs are not more effective than TCAs
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3 Opioids Opioids combine with mu, κ, and σ opioid receptors in the peripheral and central nervous system to inhibit the generation and transmission of nociceptive afferent signals to produce analgesic effects, which can relieve pain to varying degrees, but cannot Effective treatment of FM, due to the risk of addiction and adverse reactions, FM patients are not recommended to use strong opioids
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The "Consensus of Chinese Experts on the Clinical Diagnosis and Treatment of Fibromyalgia" (2021) pointed out that in certain specific patients, the use of weak opioid agonists should be considered, and then the use of strong opioids should be considered
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There is evidence that opioids may aggravate FM-related hyperalgesia and other central sensitization states
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Tramadol is a weak mu opioid receptor agonist, and it enhances the activity of 5-HT and NE.
It has a moderate improvement effect on pain, and can also resist depression and anxiety symptoms, but it does not improve health-related quality of life.
Significantly relieves burning pain, acupuncture pain and hyperalgesia, but the effect on lightning-like and knife-cutting pain is not obvious
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It has similar adverse reactions to other opioids.
Pay attention to drug tolerance or dependence
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Adverse reactions include nausea, vomiting, constipation, dizziness, urinary retention, drowsiness and headache
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Not to be used with serotonin drugs (including SNRIs) to avoid the risk of serotonin syndrome
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4 The muscle relaxant cyclobenzaprine is structurally similar to tricyclic antidepressants, which can improve the pain and sleep of FM patients, but has no obvious antidepressant effect
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Adverse reactions include drowsiness, dry mouth, dizziness, tachycardia, nausea, indigestion, fatigue and so on
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It is contraindicated in those who have taken monoamine oxidase inhibitors within 2 weeks, which can cause high fever, convulsions, and even death; contraindicated in the acute recovery period of myocardial infarction, arrhythmia, heart block or congestive heart failure, and hyperthyroidism
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Combined use with monoamine oxidase inhibitors may cause hypertensive crisis, severe convulsions, and even death.
Combination is contraindicated; combined use with tramadol can increase the risk of seizures
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5 Non-steroidal anti-inflammatory drugs (NSAIDs) NSAIDs have antipyretic, analgesic, anti-inflammatory, and anti-rheumatic effects.
The addition of NSAIDs when inflammatory pain diseases are comorbid with FM can help control inflammatory pain and help the overall disease Of relief
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The "Consensus of Chinese Experts on the Clinical Diagnosis and Treatment of Fibromyalgia" (2021) pointed out that the European Alliance against Rheumatism (EULAR) believes that NSAIDs have a weak effect on FM
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The "Guidelines for the Diagnosis and Treatment of Fibromyalgia Syndrome" (2011) pointed out that NSAIDs may be effective for FM and are often used as adjuvant drugs to improve FM pain.
There is currently no evidence-based medical data on the efficacy evaluation of NSAIDs alone
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6 Glucocorticoids have not been confirmed to be effective for the treatment of FM.
Due to the lack of effectiveness and adverse reactions, glucocorticoids are not recommended for the treatment of FM
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According to the "Guidelines for the Diagnosis and Treatment of Fibromyalgia Syndrome" (2011), it is generally believed that glucocorticoids are not effective for FM and are not recommended
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7Sedative drugsSedative drugs can shorten the time to fall asleep, reduce the number of awakenings at night, significantly improve the quality of sleep, and assist in FM
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Zolpidem and Zolpidem can improve sleep, but cannot relieve pain
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It is recommended to use it in the early stage of treatment, and it should be stopped gradually after sleep improvement, and it is not suitable for long-term use
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8Other trigger points, injection of lidocaine can be used for the treatment of FM.
Lidocaine can block voltage-gated sodium ion channels, reduce the ectopic impulse of primary afferent nerves after injury, and significantly reduce pain and reduce spinal cord sensitization , To reduce spontaneous pain, hyperalgesia and allodynia, but it is prone to adverse reactions such as hypotension, dizziness, headache, drowsiness, numbness of the lips or narrow vision
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References: [1] Chinese Expert Consensus on Clinical Diagnosis and Treatment of Fibromyalgia[J].
Chinese Journal of Pain Medicine,2021,27(10):721-727[2] Guidelines for Diagnosis and Treatment of Fibromyalgia Syndrome[J].
Journal of Rheumatology,2011,15(8):559-561[3]Jiao Juan et al.
Interpretation of 2017 European Anti-Rheumatism Alliance Fibromyalgia Treatment and Management Recommendations[J].
Chinese Journal of Rheumatology,2018,22( 1): 67-70[4] Expert consensus on drug treatment of chronic musculoskeletal pain (2018)[J].
Chinese Journal of Pain Medicine,2018,24(12):881-886[5]Diagnosis and treatment of postherpetic neuralgia Chinese expert consensus[J].
Chinese Journal of Pain Medicine,2016,22(3):161-164[6]Expert consensus on diagnosis and treatment of diabetic peripheral neuropathic pain[J].
Chinese Journal of Pain Medicine,2018,24(8): 561-565[7] Expert consensus on diagnosis and treatment of neuropathic pain[J].
Chinese Journal of Pain Medicine,2013,19(12):705-708[8]Expert consensus on perioperative application of non-opioid analgesics in adults[J ].
International Journal of Anesthesiology and Resuscitation, 2019, 40(1): 1-6