Table 3


RecommendationLevel of evidenceGradeStrength of recommendationAgreement (%)*
Overarching principles
Optimal management requires prompt diagnosis. Full understanding of fibromyalgia requires comprehensive assessment of pain, function and psychosocial context. It should be recognised as a complex and heterogeneous condition where there is abnormal pain processing and other secondary features. In general, the management of FM should take the form of a graduated approach.IVD100
Management of fibromyalgia should aim at improving health-related quality of life balancing benefit and risk of treatment that often requires a multidisciplinary approach with a combination of non-pharmacological and pharmacological treatment modalities tailored according to pain intensity, function, associated features (such as depression), fatigue, sleep disturbance and patient preferences and comorbidities; by shared decision-making with the patient. Initial management should focus on non-pharmacological therapies.IVD100
Specific recommendations
Non-pharmacological management
 Aerobic and strengthening exerciseIaAStrong for100
 Cognitive behavioural therapiesIaAWeak for100
 Multicomponent therapiesIaAWeak for93
 Defined physical therapies: acupuncture or hydrotherapyIaAWeak for93
 Meditative movement therapies (qigong, yoga, tai chi) and mindfulness-based stress reductionIaAWeak for71–73
Pharmacological management
 Amitriptyline (at low dose)IaAWeak for100
 Duloxetine or milnacipranIaAWeak for100
 TramadolIbAWeak for100
 PregabalinIaAWeak for94
 CyclobenzaprineIaAWeak for75
  • *Percentage of working group scoring at least 7 on 0–10 numerical rating scale assessing agreement.