If you go on the website of the American College of Rheumatology and search for the best treatments for fibromyalgia, you’ll find a detailed discussion of prescription medications first, followed by nondrug approaches.

That’s precisely backward.

So concludes a distinguished European expert consortium, which has now released its first major updated evidence-based treatment recommendations for fibromyalgia in nearly a decade.

Their conclusion: To relieve symptoms of this often debilitating condition, which can cause widespread pain throughout your body, pharmaceuticals should be the last thing you try.

The Europeans didn’t endorse all nondrug therapies, to be sure. One nondrug approach is strongly supported by evidence, others have some evidence behind them, a few are unproven—and one may be dangerous. They did find a few medications that may be helpful in certain circumstances—but never as a first-line treatment.

THE BEST TREATMENTS FOR FIBROMYALGIA

To determine the most effective treatments, the European League Against Rheumatism (EULAR) pulled together 18 clinicians and researchers from 12 different countries—experts in rheumatology, internal medicine, pain medicine, epidemiology, occupational health and nursing plus patient representatives. Together, they reviewed 2,979 studies and reviews. The good news is that there is much better research than the last time they convened—in 2007. Their evidence-based findings…

  • Exercise. This was the only “strong” recommendation—and it was unanimous. Exercise reduces pain, improves physical function, enhances well-being—plus it’s widely available, safe and low-cost. Research gap: It’s not known yet whether aerobic or strength training or a combo is best.
  • Meditative movement therapies (qigong, tai chi, yoga) was a “weak” recommendation—some evidence supports them. In particular, they can improve sleep, fatigue and quality of life.
  • Mindfulness-based stress reduction (MBSR), another “weak” recommendation, improves pain and quality of life.
  • Acupuncture, another “weak” recommendation, improves pain and fatigue.
  • Hydrotherapy, also “weak,” reduces pain and improves quality of life. (See Bottom Line’s article “Shiatsu Massage in a Warm Pool Can Melt Away Aches and Pains.”)
  • Not recommended: There wasn’t enough evidence to support these approaches—biofeedback, capsaicin, hypnotherapy, massage…or SAMe, a supplement. That doesn’t mean these don’t work—just that there are not good studies to establish whether they do or not.
  • Caution: EULAR recommended against chiropractic care for fibromyalgia based on lack of evidence and safety concerns.

A SMALLER, SUPPORTIVE ROLE FOR MEDICATIONS

EULAR makes it clear that drugs should never be the first treatment option. But if the above approaches aren’t working well enough, medications can be a second-line approach—based on individual symptoms and issues. Their findings…

  • Patients with “severe” pain may benefit from duloxetine (Cymbalta), pregabalin (Lyrica) or tramadol (Ultram). This was a “weak” recommendation.
  • For patients with sleep disturbances, there was another “weak” recommendation for pregabalin (Lyrica), amitriptyline (Elavil) and cyclobenzaprine (Flexeril).
  • Not recommended: NSAID painkillers such as ibuprofen and naproxen…as well as SSRI antidepressants such as Prozac—there isn’t enough evidence that they work.
  • A strong warning: EULAR concluded with a “strong against” for medications such as growth hormones, strong opioids and corticosteroids. There’s no evidence that they work, and there is a high risk of side effects.

If you have fibromyalgia or think you might have it—it often takes years to be properly diagnosed—it’s important to discuss your individual condition with your doctor. The journey back to health and feeling better can be challenging, and it’s very individual. Nor is it easy to start an exercise program when you’re fatigued, in pain and having trouble sleeping, but there are ways to make exercise safer and more comfortable. One thing is clear—the march of medical science is clearly moving toward a primary role for exercise, as well as mind-body and other nondrug approaches, in the management of this vexing condition. To learn more, see Bottom Line’s article “Real Help for Fibromyalgia.