What is fibromyalgia and is all fibromyalgia the same?

Fibromyalgia is a chronic disabling condition that causes widespread pain, fatigue and unrefreshing sleep together with several other symptoms which may vary in severity. The pathophysiology of this condition has been poorly understood for many years and patients may still remain undiagnosed. Since symptoms such as anxiety, depression, irritable bowel, migraines and painful body parts may vary between patients, fibromyalgia patients may be seen by psychiatrists, rheumatologists, neurologists, orthopaedic surgeons or anaesthetists and the diagnosis may vary depending on the specialist and the predominant symptoms. Fibromyalgia patients are often diagnosed with anxiety, depression, attention deficit hyperactivity disorder (ADHD), chronic fatigue syndrome, osteoarthritis, slipped disc, sciatica, neuralgia and sleep disorders. It can be very frustrating for patients who are sometimes diagnosed with a medical condition but still have many unexplained symptoms. Such patients may decide to get a second opinion from another specialist and end up with another diagnosis. Since the symptoms of fibromyalgia can vary greatly between patients, prescribing the right treatment can be quite challenging, especially since what can work for one fibromyalgia patient may not work for another.

Commonly prescribed medicines for fibromyalgia

Pregabalin, also known as Lyrica or Pragiola, is an anti-epileptic drug that can help reduce nerve sensitivity and is usually prescribed when the pain is severe. It also helps with anxiety and promoting sleep. Side effects include dizziness, memory loss, vision problems and weight gain. Gabapentin and Carbamazepine are similar drugs that sometimes work better, e.g. in trigeminal neuralgia where the most painful nerve is that of the face.

Duloxetine, also known as Cymbalta, is a serotonin and noradrenaline re-uptake inhibitor (SNRI) and is usually prescribed when there are predominant symptoms of anxiety and depression. This drug works well for some patients and they may experience a significant reduction in symptoms when starting this medication, including a reduction in pain and an improvement in sleep. However, after several months of using this medicine, the effectiveness may start reducing, needing an increase in dose which is not always effective and can cause side effects such as nausea, weight gain, mood fluctuations and increased pain. Similar drugs that are sometimes prescribed include Sertraline (SSRI) and Venlafaxine (SNRI) which help reduce pain sensitivity and anxiety/depression  symptoms through their effect on serotonin and noradrenaline.

Amitriptyline, also known as Amirol or Tryptizol is a very old drug known as tricyclic antidepressant that has been prescribed for many years and was the most commonly prescribed medicine for patients with symptoms of fibromyalgia until the newer SSRIs and SNRIs became available. It is still quite commonly prescribed as it helps normalize serotonin while promoting sleep through its sedative effect. It is commonly taken at night and common side effects may include a hangover effect and weight gain. After several months, the starting dose may not remain effective and an increase in dose may be needed, with the result that the patient may experience more side effects. Nortriptyline, known as Nortrilen, is sometimes prescribed as an  alternative as patients may experience less side effects with it.

Tramadol is an opiate drug that is prescribed when pain is severe. It is often effective to reduce pain levels but long-term use of opiates is not recommended for various reasons. Common side effects of opiates include sedation, intoxication, respiratory depression, fertility problems, dependence and tolerance. With time the pain-relieving effect of opiates reduces and long-term use can even result in a condition causing increasing pain known as opiate-induced hypersensitivity. Increasing the dose can cause serious side effects including death. Opiates are only recommended for short-term use under the constant supervision of a medical professional. Codeine and dihydrocodeine are sometimes also prescribed for chronic pain but constipation and addiction make them unsafe for long-term use.

Very often, patients with fibromyalgia symptoms also have bowel issues and the medication can make these symptoms worse. Even though most medication does help relieve symptoms, side effects may sometimes be worse than the symptoms that are being treated so patients often opt to stop the medication and try to manage their symptoms in the most natural way possible. After all, fibromyalgia is a central hypersensitivity syndrome which means that patients are very sensitive to everything, including medication and many patients cannot tolerate most medicines because of side effects.

What causes fibromyalgia?

Now that we are familiar with some of the symptoms of fibromyalgia (there are many more than what was mentioned), let us try and understand what causes this mysterious condition and why symptoms seem completely unrelated to each other. Understanding the physiology of this condition and what goes wrong in the body will explain why patients respond the way they do to some medications and not others and why certain approaches to managing this condition work better than others.

Before explaining what goes wrong in the body, we need to understand how a normal person’s body works. The endocannabinoid system (ECS) is an extensive network of receptors and neurotransmitters that is widespread throughout the body and controls many of the body’s important functions including pain management, mood, appetite, sleep, bowel function, stress management and many others. This system of receptors was only discovered in the early 1990s and this knowledge was missing from the medical curriculum until recently. This means that most doctors were not aware that this system existed when they graduated and therefore symptoms associated with abnormalities in this system could not be easily explained. To complicate matters, this extensive system of receptors which works using the body’s endogenous cannabinoids only responds to medical cannabis, which is also a drug which was highly stigmatized for years and only became legally available in recent years, meaning that research on this system was very difficult to carry out.

The function of the ECS is to maintain homeostasis in the body, which means that it keeps everything working in optimal condition. It controls mood through neurotransmitters such as serotonin, dopamine and noradrenaline. It controls hormones such as the thyroid. It controls metabolic processes which influence blood sugar levels and cholesterol. It controls the electricity in the nervous system. It protects us against infections and chronic illnesses. It controls allergies, gut function and many other bodily functions making it one of the most important systems in the body.

The ECS, like any other system in the body, can malfunction for various reasons. There is a strong hereditary component which makes women and their daughters more likely to develop this condition. Stress, trauma, infection, and chronic illness can also trigger the onset of a malfunction of the ECS. When this happens, the patient develop symptoms of loss of homeostasis. Nerve pain in various parts of the body is the most common symptom because of loss of control over the electricity in the nervous system. This can also lead to anxiety, depression, attention deficit, brain fog and sleeping difficulties. Other symptoms of abnormal homeostasis may include allergies, asthma, type 2 diabetes, high blood pressure and hypothyroidism, depending on which system is predominantly affected.

When the ECS malfunctions and our homeostatic mechanism is affected, the patient develops symptoms of fibromyalgia. But not all fibromyalgia is the same. It can vary in type and severity. There is a large spectrum of varying severity and patients can move from one end of the spectrum (severe) to the other end (mild) by adopting certain lifestyle changes and using natural remedies to ease their symptoms. However, there is no cure for fibromyalgia. Patients will get symptoms when they are under stress and when they do not manage their condition well. All patients can manage their symptoms if they get the right advice, prioritize self-management and keep it up daily.

What are the different types of fibromyalgia and how can they be managed?

Besides being challenging to diagnose, fibromyalgia can be extremely challenging to manage. We have seen that most medications prescribed for fibromyalgia are not always effective and often cause disabling side effects. Understanding what causes fibromyalgia can make it easier to manage.

Since fibromyalgia patients may be diagnosed by various specialists, this means that they will be advised differently on how to manage their condition. Rheumatologists often prescribe pain-relieving medication such as Pregabalin and Tramadol. Psychiatrists may prescribe medication to address anxiety and sleeping difficulties. Anaesthetists may offer interventional procedures to block some nerves which may be causing severe pain. Whatever the case, patients need to be aware that the medication is not a solution and self-management is very important.

When making a diagnosis of fibromyalgia, it is important to realize that this is caused by an imbalance in the nervous system. Abnormal neurotransmitter levels may be causing increased pain, low mood, unexplained anxiety, problems focusing, brain fog, difficulty sleeping or some other symptoms. A thorough assessment is important to understand what neurotransmitter is being predominantly effected. A previous diagnosis of ADHD may indicate there is an imbalance in dopamine. A diagnosis of anxiety and depression might point to an imbalance in serotonin. A good response to opiates might indicate abnormal endorphin levels. Pain relief using medical cannabis might indicate that the ECS is predominantly effected. The assessment of a patient with fibromyalgia can tell us a lot about what could work for this patient and what wouldn’t. Patients may have already tried some prescribed medications or some over-the-counter supplements such as cannabidiol (CBD) and may report a therapeutic effect.

After taking a detailed history and examining the patient, there would be a good indication of the severity of the condition and on what possible medications could help. Patients with fibromyalgia often lack restful sleep and restoring that is a priority for improvement. Chronic pain may prevent patients from moving much and they often do not do much physical activity. Guiding patients on starting gentle, low-impact exercise is key to restore normal function in the muscles and ease the pain associated with stiffness. Since there are a lot of endocannabinoid receptors in the bowel and patients are often sensitive to certain foods such as dairy, gluten and sugar, it is advisable to eat natural foods which do not negatively impact the gut. Alcohol should be avoided as it can damage the gut and worsen symptoms in the long-term, although some patients may find it works to relieve their symptoms in moderate doses. Processed food should be avoided as its effect on the gut can vary between patients. Since the gut in fibromyalgia patients is very delicate and patients cannot eat what they want, supplementation is often recommended. Magnesium, Vitamin B, D, E, Omega 3 and probiotics all help to support the ECS.

Medical cannabis has been found to be a safe and effective treatment for patients with fibromyalgia. Since patients with fibromyalgia often have low levels of endogenous cannabinoids (endocannabinoid deficiency), meaning that the natural tetrahydrocannabinol (THC) in the nervous system is lower than normal, supplementing these with plant-based cannabinoids can help restore normal function to the ECS, with the result that most symptoms of fibromyalgia improve.

Patients using medical cannabis report reduction in their baseline pain levels by half, improved sleep quality and more stable moods with reduced anxiety levels. This inevitably results in an improved quality of life with very little or no negative side effects. Since medical cannabis works by restoring normal function to the ECS, homeostasis improves and patients may also experience improvement in their allergies, asthma, blood pressure, blood glucose and cholesterol levels. Chronic pain conditions respond positively to medical cannabis with the result that patients live a normal life, having the pain at a very low level in the background. Even though symptoms of fibromyalgia may sometimes seem as if they’ve disappeared, they often return when the medication is stopped or when the patient is under stress.

What is CBD and how can it help?

Since fibromyalgia is caused by an imbalance in the endocannabinoid system (ECS), one must try to restore normal function in this system in the most natural way possible to avoid unnecessary side effects. The three most important factors to address in patients with fibromyalgia are sleep quality, dietary choices and physical activity. When patients are anxious and/or in pain, it may be challenging to address these issues without some help.

Both cannabidiol (CBD) and cannabigerol (CBG) are non-intoxicating herbal supplements that can be accessed without a prescription and have been shown in various studies to help with anxiety, pain and sleep to various degrees. They work by restoring balance to the ECS without any negative side effects and can help some patients manage their symptoms better. However, CBD and CBG do not work in the same way for everyone. While the positive effect on reducing anxiety is quite universal, their effect on chronic fibromyalgia pain is not always sufficient. Some patients do really well and manage their symptoms with just CBD or CBG or both, while others do not respond and would need prescribed medical cannabis, especially when sleeping is also a problem.

At Medifood, we offer free consultations to advise fibromyalgia patients how they can manage their symptoms in the most natural way possible using supplements which can be accessed over the counter without a prescription. While some patients respond well, others may need referral to The Pain Clinic for a consultation, assessment and a prescription for medical cannabis with THC. We try to explain the various symptoms that the patient is experiencing in the simplest way possible and reassure patients that we can help them ease their symptoms. We advise on a trial of CBD and/or CBG and follow-up in 3-4 weeks. If the patient responds positively, we fine tune their supplements to obtain the best effect possible. If the patient doesn’t respond, we recommend a 1-hour initial assessment at The Pain Clinic where we would then apply for medical cannabis with THC and advise how this can be used to manage fibromyalgia symptoms. Over 95% of patients with fibromyalgia on medical cannabis respond very well, since this helps correct the imbalance in the ECS and restores normal homeostasis. Combining medical cannabis with various health supplements usually improves the response and provides a superior therapeutic effect.

If you are experiencing unexplained pain or anxiety, fatigue, problems focusing, brain fog or sleeping difficulties, or any other symptom which has not responded to medication, feel free to get in touch by booking a consultation for free medical advice where we can explain your symptoms and recommend an over-the-counter supplement. If you don’t respond after 3-4 weeks, we will refer you to The Pain Clinic for a consultation where you can get a prescription and advice on how you can ease your pain and improve your quality of life like many of our patients using natural medicines and supplements.

Dr Andrew Agius is the founder and medical director of The Pain Clinic and the co-founder of Medifood Malta. He has been treating patients with fibromyalgia since 2015 and has a passion for helping patients with chronic pain improve their quality of life.