EULAR recommendations for the management of fibromyalgia

EULAR recommendations for the management of fibromyalgia


EULAR recommendations give advice to doctors, nurses and patients about the best way to treat and manage diseases. EULAR has updated its recommendations on looking after people with fibromyalgia, a rheumatic condition that is associated with widespread pain and fatigue. People with fibromyalgia may also report headaches, migraines, non-refreshing sleep, mood disturbances and bowel or stomach problems.

A group of 18 experts worked together to develop the recommendations.

What do we already know?

About 2% of people have fibromyalgia, but it is difficult to diagnose and manage. People with fibromyalgia often see several doctors before they are diagnosed.

What do the recommendations say?

It is important to diagnose people with fibromyalgia quicker so that they can get the treatment they need. Full understanding of fibromyalgia needs an assessment of pain, function and the impact on a person’s mental and social wellbeing. Management of fibromyalgia should aim at improving quality of life and balancing the benefits and risks of treatment. This might mean needing a combination of different types of drug and non-drug treatments, agreed together by a person and their doctor. In the first instance, management should focus on non-drug treatments. People with fibromyalgia generally report preferring non-drug treatment.

Overall, there are ten recommendations. These are split into two main areas. The first looks at general non-drug management of people with fibromyalgia. The second part looks at drug treatments.

Each recommendation is based on available scientific evidence or expert opinion. The more stars a recommendation has the stronger the evidence is and the more important it is that patients, doctors and nurses follow it.

One star (*) means it has limited evidence.

Two stars (**) means it has some evidence.

Three stars (***) means it has quite a lot of evidence.

Four stars (****) means it is supported by a lot of evidence.

General management and treatment of people with fibromyalgia

  • Aerobic and strengthening exercise ****
    Exercise that works and strengthens muscles of the body, either on land or in water, can reduce pain, although it may increase pain at the very beginning. Resistance training with weights, may be beneficial also.
  • Cognitive behavioural therapy ***
    Cognitive behavioural therapy (also called CBT) is a talking therapy that teaches people to challenge negative ideas. It may help to change the way people think and behave. This could help to manage the pain of fibromyalgia and give them ways of coping.
  • Multi-component therapies **
    Multi-component therapies may include different combinations of exercise, education,relaxation, or some other specific treatments such as Tai Chi or massage. This can help todeliver short-term improvements in pain and fatigue.
  • Acupuncture or hydrotherapy **
    Traditional or electric acupuncture can help to improve pain when added to other treatments.Hydrotherapy or spa therapy sessions can deliver improvements that last for up to 14 weeks.
  • Meditative movement therapies and mindfulness-based stress reduction **
    Meditative movement techniques such as Qigong, Yoga or Tai Chi or the practice of mindfulness and stress-reduction can help to improve sleep and fatigue

Drug treatments for people with fibromyalgia

  • Lose-dose amitriptyline **
    Amitriptyline is an antidepressant drug that can help to reduce pain and fatigue as well as improving sleep quality when taken at low doses of up to 25 mg per day.
  • Duloxetine or milnacipran **
    Duloxetine and milnacipran are another type of antidepressant drug. These should be considered in people with severe pain.
  • Tramadol **
    Tramadol is a weak type of opioid drug. It should be considered in people with severe pain.
  • Pregabalin **
    Pregabalin is an anti-convulsant drug that may be useful in fibromyalgia to reduce pain and improve sleep. It should be considered in people with severe pain or sleep disturbance caused by fibromyalgia.
  • Cyclobenzaprine**
    Cyclobenzaprine can help to improve sleep, but most people also experience side effects. It should be considered in people with sleep disturbance caused by fibromyalgia.


Overall, the recommendations suggest using a mix of approaches to manage fibromyalgia. These will depend on a person's own specific symptoms. For people with fibromyalgia these recommendations will give some guidance on what they can expect from their treatment.

If you have fibromyalgia and have any questions or concerns about your disease or your medication, you should speak to a health professional involved in your care. Patient organisations may also be useful to help you find support and information.

Where can I find out more?

This is the patient version of the EULAR recommendations for the management of fibromyalgia. The original publication can be downloaded here.