Evolving Concepts in the Diagnosis and Management of Fibromyalgia: A Moving Target

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Abstract: Fibromyalgia (FM) is a chronic, multifactorial pain syndrome involving widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive dysfunction, significantly reducing the quality of life of patients. FM is classified under MG30.01, representing chronic widespread pain, within the broader classification of chronic primary pain according to the International Classification of Diseases, 11th Revision. FM has a complex, multifactorial pathophysiology involving peripheral and central mechanisms that contribute to its marked clinical heterogeneity. Currently, FM is diagnosed primarily through clinical assessment using widely accepted criteria, such as the American College of Rheumatology criteria, most recently revised in 2016, which evolved from the widely used 2010/2011 diagnostic framework. A thorough differential diagnosis is required to distinguish FM from a wide range of rheumatic, neurological, endocrine, psychiatric, and other medical disorders. FM management requires a multidisciplinary approach. Non-pharmacological interventions, including patient education, exercise (eg, aerobic and resistance training), and psychological therapies, such as cognitive behavioral therapy, are recommended as first-line treatments. Pharmacological therapies, including pregabalin, duloxetine, milnacipran, and cyclobenzaprine, are Food and Drug Administration-approved and provide clinically meaningful benefits to patients with FM. Although tramadol may be considered, the use of other opioids is generally not recommended because of their limited efficacy and potential risks. Despite the availability of current diagnostic criteria and treatment options, achieving a consistent diagnosis and optimal outcomes in patients remains challenging. Therefore, this narrative review aims to provide a concise, updated, and clinically relevant overview of the current evidence regarding the pathogenesis, diagnosis, and multidisciplinary management of FM to improve diagnostic accuracy and support individualized patient management. Furthermore, future directions should prioritize improving diagnostic precision and developing mechanism-based interventions targeting the underlying pathophysiology of FM. Keywords: fibromyalgia, chronic widespread pain, central sensitization, diagnosis, multimodal therapy

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