Medications:

In 2007 the Food and Drug Administration approved Pregabalin (Lyrica) as the first drug specifically for the treatment of fibromyalgia. Other drugs used to treat fibromyalgia are antidepressants or muscle relaxants. The goal has been to improve sleep and pain tolerance. Medications from other drug classes (such as sleeping aids and pain relievers) may also be prescribed. Patients receive drug treatments in combination with exercise, patient education, and behavioral therapies.

Anti-Seizure Agents (Anti-Convulsants)

Pregabalin is an anti-epileptic. Also called anti-seizure drugs and anti-convulsants, these medicines affect the chemical messenger gamma aminobutyric acid (GABA), which helps prevent nerve cells from over-firing.

Pregabalin was approved in 2004 to treat nerve pain and diabetic peripheral neuropathy. Research is indicating it may improve sleep quality, fatigue symptoms, and fibromyalgia pain. One study found that three different doses of pregabalin -- 300 mg, 450 mg, and 600 mg -- were all effective at improving pain and sleep, and all were well tolerated by patients. The most common side effects include mild-to-moderate dizziness and sleepiness. Pregabalin can impair motor function and cause problems with concentration and attention. Patients should talk to their doctor about whether pregabalin may affect their ability to drive.

Studies have shown that another anti-convulsant, gabapentin (Neurontin), which is approved for the treatment of postherpetic neuralgia, affects pain transmission pathways and may relieve pain associated with fibromyalgia. Patients who took gabapentin also reported that they slept better and were less tired.

Antidepressants

The main classes of antidepressants used for treating fibromyalgia are tricyclics, selective serotonin-reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs). Although these drugs are antidepressants, doctors prescribe them to improve sleep and relieve pain in non-depressed patients with fibromyalgia. The dosages used for managing fibromyalgia are generally lower than dosages prescribed for treating depression. If a patient has depression in addition to fibromyalgia, higher doses may be required.

Tricyclics. Tricyclic antidepressants were the first drugs to be well-studied for fibromyalgia. They cause drowsiness and can be helpful for improving sleep. The tricyclic drug most commonly used for fibromyalgia is amitriptyline (Elavil, Endep), which produces modest benefits with pain, but can lose effectiveness over time. Other tricyclics include desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), amoxapine (Asendin), and nortriptyline (Pamelor, Aventyl).

Generally, only small doses of tricyclic antidepressants are needed to relieve fibromyalgia. Therefore, although tricyclics have several side effects, these side effects may be less frequent in fibromyalgia patients than in those taking tricyclics for depression. Side effects most often reported include:

• Blurred vision
• Difficulty urinating
• Dizziness
• Drowsiness
• Dry mouth
• Heart rhythm disturbances
• Sexual dysfunction
• Weight gain

As with all medications, tricyclic antidepressants must be taken as directed. An overdose can be life-threatening.

Unfortunately, not all patients respond to tricyclics, and their effects wear off in some patients, sometimes after only a month.

Selective Serotonin-Reuptake Inhibitors. Selective serotonin-reuptake inhibitors (SSRIs) increase serotonin levels in the brain, which may have specific benefits for fibromyalgia patients. Commonly prescribed SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and fluvoxamine (Luvox). Studies suggest they may improve sleep, fatigue, and well-being in many patients. Studies are mixed on whether they improve pain. SSRIs should be taken in the morning, since they may cause insomnia. Common side effects are agitation, nausea, and sexual dysfunction, including a delay or loss of orgasm and low sex drive.

Serotonin-Norepinephrine Reuptake Inhibitors. Serotonin-norepinephrine reuptake inhibitors (SNRIs) are also known as dual inhibitors because they act directly on two chemical messengers in the brain -- norepinephrine and serotonin. These drugs appear to have more consistent benefits for fibromyalgia pain than SSRIs.

SNRIs include:

• Duloxetine (Cymbalta) has been approved by the FDA for treating fibromyalgia. In studies, it reduced fibromyalgia pain by more than 30%. The most common side effects with this medication are nausea, dry mouth, constipation, decreased appetite, sleepiness, increased sweating, and agitation. It may also increase the risk of hemorrhage in patients taking NSAIDs, aspirin, or blood thinners.
• Venlafaxine (Effexor) is similar to fluoxetine (Prozac) in effectiveness and tolerability for most patients. As with SSRIs, and unlike other newer antidepressants, venlafaxine impairs sexual function. Although clinical trials have shown that the drug is safe and effective in most people, there have been reports of changes in blood pressure. There have also been reports of problems with the electrical system of the heart in people taking this drug. These side effects may cause serious problems in elderly patients. Some patients report severe withdrawal symptoms, including dizziness and nausea.
• Milnacipran (Ixel) is under investigation and is not yet approved in the United States. It is specifically being researched for helping people with fibromyalgia and similar pain syndromes. Milnacipran appears to improve fibromyalgia pain and other symptoms, including fatigue, poor sleep, and depression.

Muscle Relaxants

Cyclobenzaprine (Flexeril) relaxes muscle spasms in specific locations without affecting overall muscle function. It helps relieve fibromyalgia symptoms. Cyclobenzaprine is related to the tricyclic antidepressants and has similar side effects, including drowsiness, dry mouth, and dizziness.

Sleep Medications

Zolpidem (Ambien) or other newer sleep medications such as zaleplon (Sonata) and eszopiclone (Lunesta) may improve sleep in patients with insomnia.

Pain Relievers

Pain relief is of major concern for patients with fibromyalgia. Pain relievers for fibromyalgia include:

• Tramadol (Ultram), used alone or in combination with acetaminophen (Tylenol), is commonly prescribed for relief of fibromyalgia pain. Its most common side effects are drowsiness, dizziness, constipation, and nausea. Tramadol should not be used in combination with tricyclic antidepressants.
• For relief of mild pain, acetaminophen is most often recommended. Anti-inflammatory drugs, which are commonly used for arthritic conditions, are less useful for the pain of fibromyalgia, because the pain is not caused by muscle or joint inflammation. Anti-inflammatory drugs include corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen (Advil).
• Capsaicin (Zostrix) is an ointment prepared from the active ingredient in hot chili peppers. Capsaicin is helpful for relieving painful areas in other disorders. It may also have some value for fibromyalgia patients.
• Opioids, or narcotics, may be used occasionally by certain patients with moderate-to-severe pain, or those with significant problems performing everyday tasks. Such patients should use narcotics only if they cannot find relief with other, less potent treatments. Patients may get combinations of narcotic pain relievers and acetaminophen for periodic pain. Some physicians prescribe opioids, such as oxycodone (Roxicodone) or morphine sulfate (Duramorph), for patients who need ongoing relief. However, the benefit of opioids in fibromyalgia treatment is highly controversial. Physicians should take a careful medical and psychological profile of the patient before prescribing opioids, and then should evaluate those patients periodically for continuing pain relief, side effects, and signs of dependence.
• Pramipexole, a drug used to treat Parkinson's disease and restless legs syndrome, may help relieve pain and fatigue in people with fibromyalgia. Pramipexole stimulates the production of dopamine, a chemical messenger in the brain.
• The atypical antipsychotic drug olanzapine (Zyprexa) may be a beneficial add-on therapy for patients with fibromyalgia. Although proven effective for some chronic pain conditions, olanzapine and other antipsychotics cause unpleasant and potentially serious side effects.

Other Investigative Drugs

Tropisetron. Tropisetron (Navoban) is a drug used to reduce vomiting during chemotherapy. European studies suggest that it may also help patients with fibromyalgia by reducing pain, dizziness, and depression, and by improving sleep. Fatigue and dizziness are the most common side effects.

Nabilone. A synthetic drug derived from marijuana may be another effective addition to fibromyalgia treatment, according to early studies. In one study, nabilone (Cesamet), which is also used to treat severe nausea and vomiting in chemotherapy patients, significantly relieved fibromyalgia pain compared to placebo. There are some challenges to using nabilone for fibromyalgia, however. First, it is a controlled substance that can become addictive, and researchers say it is so expensive that it would be cost-prohibitive to use for a chronic disease such as fibromyalgia.