Diffuse, Persistent Pain in a 35-year-old Woman

[[{"type":"media","view_mode":"media_crop","fid":"42159","attributes":{"alt":"","class":"media-image media-image-right","height":"307","id":"media_crop_9129293252667","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4536","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"©MichalKowalski/Shutterstock.com","typeof":"foaf:Image","width":"238"}}]]A 35-year-old woman comes to see you because of widespread pain that she says began approximately 3 months ago. She had been in her usual state of good health when she began to experience pain in her legs, upper and lower back, abdomen and shoulders. A few weeks prior to the onset of the pain she had a severe cold but can't recall any other health problem around that time. In addition to the pain she reports having problems sleeping, some morning stiffness, and has noticed that unless she makes an effort to concentrate, she at times has trouble with her memory. 

She has tried ibuprofen and naproxen for the pain, both of which have alleviated other types of pain she has had in the past but they haven't had much effect on the current pain. She even tried oxycodone with tylenol that she had left over from dental surgery last year but while this sedated her, it didn't provide much relief from the pain.

The patient is a high school math teacher. She lives with her husband, a firefighter, and their 6- and 3-year-old children. While she admits that at times it is challenging for them to both hold full-time jobs while raising two young children, there have been no recent new stresses in her life.  She has felt depressed at times recently about the pain and concerned that it may not go away but denies that these feelings have interfered with her functioning. She has no history of mental illness. She denies any history of overseas travel for the past year.

You examine the patient and except for some tenderness over the painful areas, you do not find any other problems. You order a CBC and metabolic panel both of which are normal.

1. Based on the history, physical, and lab work, which diagnosis would you consider to be most likely?

A. Lyme disease

B. Chronic fatigue syndrome

C. Fibromyalgia

D. Major depressive disorder

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Answer: C. Fibromyalgia

All of these disorders can present with similar symptoms including marked pain and it can be difficult to differentiate between them.

If the patient lived in or had visited an area where Lyme disease is common before the onset of symptoms, this should be considered especially if she recalls a tick bite or presence of a rash and further workup for this would be indicated.

With regard to the other three, the patient essentially denies the symptoms required to make the diagnosis of major depressive disorder and pain rather than fatigue is the major presenting symptom, so fibromyalgia (FM) is the most likely diagnosis. 

2. Which of the following also fit/s with the diagnosis of FM?

A. The presence of the morning stiffness, problems sleeping, and some memory problems

B. The absence of other explanations for her symptoms

C. The presence of the cold prior to onset of the pain

D. A and B

E. All of the above

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Answer: D. A and B 

All three of the problems in option A commonly occur with FM.  If there are other disorders that explain the pain, FM would not be diagnosed. Although it has been speculated that infectious diseases may be a risk factor for FM, this has not yet been proven.

3. According to the currently used diagnostic criteria for FM, which of the following would be required to make the diagnosis?

A. Scores on the Widespread Pain Index (WPI) and the Symptom Severity Scale (SSI)

B. The presence of the pain for at least 3 months

C. Counting the number of tender points the patient has

D. A and B

E. A and C

F. All of the above

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Answer: D.  A and B

The current American College of Rheumatology diagnostic criteria for FM require that the WPI and SSI be administered to patients in order for the diagnosis to be made and that the pain be present for at least 3 months. An earlier version of the criteria required that a certain number of tender points be present but this is no longer required.

You make the diagnosis of FM. You believe a trial of medications may be beneficial. 

4. Which classes of medication appear to be most efficacious for the management of FM:

A. Serotonin-norepinephrine reuptake inhibitors

B. Opioids

C. Non-steroidal anti-inflammatory drugs

D. Anticonvulsants

E. A and D

F. B and D

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Answer: E. A and D

FM appears to respond best to treatment with serotonin-norepinephrine reuptake inhibitors and anticonvulsants. The only drugs that are FDA approved for the treatment of this disorder, duloxetine (Cymbalta), milnacipran (Savella), and pregabalin (Lyrica), are in these two categories.  Unfortunately, as of yet there is little guidance as to which of the two classes or the individual medications is most likely to be beneficial for an individual patient.

Do you treat patients with fibromyalgia? What medications/modalities do you find most successful?

References:

Agency for Healthcare Research and Quality. Treatment of fibromyalgia in adult subgroups. AHRQ Publication No. 15-EHC006-EF. Jan. 2015

Centers for Disease Control and Prevention. Fibromyalgia. Available at:
http://www.cdc.gov/arthritis/basics/fibromyalgia.htm.

Wolfe F, Clauw DJ, Fitzcharles MA, et al.  Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR preliminary diagnostic criteria for fibromyalgia. J Rheumatol. 2011;38:1113-1122.