A Deep Dive Into Fibromyalgia Pain

Fibromyalgia pain is not like other kinds of pain. It doesn’t always indicate something is awry with the body part that hurts, and it doesn’t respond to many treatments that usually help alleviate pain.

Fibromyalgia pain is believed to come from complex and interrelated dysfunctions throughout the nervous system (brain, spinal cord, and nerves).¹² It can manifest in many ways. The pain type and pattern can differ from one person to the next.

This article explores where you might feel pain, the nature of that pain, what flares feel like, what is happening with pain signals in your brain, and how to live better with fibromyalgia pain.

Fibromyalgia Pain Points on Body

Fibromyalgia pain can occur anywhere on your body. It may stay confined to certain places, it may be everywhere at once, or it may move around unpredictably.

Pain From Pressure

Many people with fibromyalgia have abnormal pain types called hyperalgesia, allodynia, and paresthesia, which are as follows:³

• Hyperalgesia is heightened pain—something that would normally cause discomfort produces more pain than usual.⁴ An example is a tight waistband on a pair of jeans. It might be mildly painful for most people, but someone with fibromyalgia may experience searing pain.
• Allodynia is pain from something that shouldn’t cause pain, such as a soft, loose waistband or bathrobe tie.⁴ While most people feel no discomfort, a person with fibromyalgia may be in severe pain. Allodynia may also amplify the effect of heat or cold on your skin, called thermal allodynia.⁵
• Paresthesia is an abnormal nerve sensation. It can cause tingling, itching, crawling, burning, or “zinging” pain.⁶ Paresthesia may be spontaneous, or it may be a response to pressure on the body. It isn’t always painful but is more likely to cause pain in people with fibromyalgia.

You may have any combination of hyperalgesia, allodynia, and paresthesias. They may come and go, or they may be constant.

Fibromyalgia Tender Points

As you learn about fibromyalgia pain, you’re bound to come across a tender point chart, typically a picture of the body with pairs of red dots at nine locations from head to toe. If you don’t feel pain at those points, does it mean you don’t have fibromyalgia?

No, not at all. While some people with fibromyalgia may actively feel pain at some of those points, most people do not unless pressure is applied. Tender points aren’t a fibromyalgia symptom. They’re an outdated diagnostic tool that measures widespread tenderness.

In 2010, the American College of Rheumatology adopted diagnostic criteria that don’t involve tender points.⁷

Where Fibromyalgia Hurts

Where fibromyalgia causes active, noticeable pain—and not just general tenderness—is different for everyone. 

It may be determined by where you’ve had previous injuries, surgeries, or other trauma. On the other hand, it may not be tied to any reason you can identify.

Describing Fibromyalgia Pain and Flares

Fibromyalgia pain can be hard to describe, especially since it can change significantly from one day (or one minute) to the next. It’s sometimes described as a full-body migraine.

Some people with fibromyalgia feel an intense, sunburn-like pain on the skin all over their bodies. Some people experience stabbing, shooting, or zinging pains, while others may have a deep ache. You may have several different types of pain, and they may come and go.

What Is a Fibromyalgia Flare?

A fibromyalgia flare is when fibromyalgia pain (and other symptoms) is especially bad. When symptoms lessen, it’s called remission.⁸

Not everyone with fibromyalgia has flares and remissions, but they are extremely common. Flares may be triggered by a variety of factors, such as: 

• Stress (emotional or physical, such as illness or injury)
• Lack of sleep
• Overexertion
• Weather changes⁹
• Hormone fluctuations¹⁰

Your pain during a flare may get worse or be a different type altogether. For example, you may often have diffuse aches but have stabbing abdominal pains during flares.

Studies suggest flu-like symptoms (body aches, fatigue, exhaustion) are common in flares but not present the rest of the time.⁹

Learning about your flares can help you avoid or lessen them. For example, if your flares are triggered by stress, and you know you have a stressful time coming up, you may want to increase your self-care (getting extra sleep, taking more time to relax) before that time.

Also, if you can recognize the early signs of a flare, you may be able to take steps to minimize the symptom increase.

Fibromyalgia Pain and Brain Signaling

Fibromyalgia pain involves abnormal brain signaling and other activity and dysfunction throughout the central and peripheral nervous systems. These systems are:

• Central nervous system (CNS): The brain and spinal cord
• Peripheral nervous system (PNS): Nerves that connect your CNS to the rest of your body

The prevailing theory of what causes fibromyalgia pain is central sensitization. This means the central nervous system has become hypersensitive to stimuli. While pain is the main focus, it can also cause an extreme reaction to noise, light, odor, and temperature.⁶

This complex set of dysfunctions involves anatomical, structural, neurochemical, and immunological changes. Some of these brain-based problems involve:¹¹

• Neuroinflammation: Driven by over-activity in the brain’s dedicated immune system, brain inflammation may be tied to many fibromyalgia symptoms.
• Small-fiber neuropathy: Studies link pain from small-fiber nerve damage and hyperexcitability to fibromyalgia. These nerves relay pain and temperature signals to your brain.
• Degeneration: Likely caused by inflammation, some nerves related to the eyes show damage on brain scans. In one study, more degeneration correlated with more severe symptoms.¹²
• Neurotransmitters: Dysregulated brain chemicals include excess glutamate activity (stimulates the brain) and low activity of gamma-aminobutyric acid (GABA), which calms the brain).
• Activity, connectivity, and volume: Brain regions that handle pain processing are overactive, form excessive connections with other brain regions, and tend to be larger or smaller than usual. 
• Nociceptors: Also called pain receptors, these nerve endings are all over your body. In fibromyalgia, nociceptors have a heightened sensitivity to touch and pressure.¹³
• Extra nerves: In addition to heightening sensitivity, extra nerves in fibromyalgia affect temperature-related blood flow and may be involved in temperature dysregulation.¹⁴
• Dorsal root ganglia: Research has suggested an abnormality in these nerve structures along the spine may be the origin of fibromyalgia pain.¹⁵

For experts, this all paints a picture of a brain and nervous system that overreacts to stimuli and amplifies—or even creates—pain and other fibromyalgia symptoms.

Fibromyalgia Pain Management

Fibromyalgia pain is hard to treat. While there are many treatment options, they don’t all work for everyone. It usually takes multiple approaches to achieve meaningful relief.

Getting a referral to a pain specialist may help you explore the range of treatments available and avoid those that might not be recommended for your unique health considerations.

Medication

Prescription medications are a common part of a fibromyalgia treatment regimen. The drugs approved by the Food and Drug Administration (FDA) are:¹⁶

• Lyrica (pregabalin): An antiepileptic drug (treats epilepsy) that can treat several types of neuropathic pain
• Cymbalta (duloxetine): An antidepressant that helps regulate certain neurotransmitters
• Savella (milnacipran): A drug with FDA approval only for fibromyalgia but that’s marketed in other countries as an antidepressant

Many other medications are used off-label (without FDA approval) for fibromyalgia. These include:¹⁶

• Other antidepressants, such as amitriptyline
• Experimental drugs, including low-dose naltrexone (LDN)
• Muscle relaxants such as Flexeril (cyclobenzaprine)
• Opioid painkillers such as Vicodin (hydrocodone-acetaminophen)
• Anti-inflammatories such as Relafen (nabumetone), Motrin/Advil (ibuprofen), or Aleve (naproxen sodium)

It should be noted that despite common use, opioids and anti-inflammatories are not generally recommended for treating fibromyalgia. Neither are common sleep medications like Ambien (zolpidem) or Lunesta (eszopiclone).¹⁶

 Opiates for Fibromyalgia and Chronic Fatigue Syndrome

Exercise and Physical Therapy

Exercise is the most recommended treatment for fibromyalgia, although this is controversial in the community of people with fibromyalgia. In studies, it’s been shown to be consistently effective.¹⁷

Common types of exercise for fibromyalgia include:¹⁷

• Warm-water exercise
• Yoga
• Tai chi
• Other low-impact aerobic activity

Working with a physical therapist may help you get started the right way. They can assist you with evidence-based types of exercise, such as:¹⁷

• Aerobic activity
• Muscle strengthening
• Flexibility exercises

The key is to start slowly and work up gradually. Otherwise, you risk putting yourself into a flare.¹⁸

Stress Management and Mental Health Therapy

Stress is believed to be a major trigger of fibromyalgia symptoms, so stress management is important.¹⁶ A mental health practitioner may be able to help you minimize the impact of stress on your symptoms.

Stress management and exercise can be combined if you do yoga or tai chi.¹⁶ Meditation and mindfulness can also help.¹⁹

If you have depression, which is common in people with fibromyalgia, you may want to try cognitive behavioral therapy (CBT). This well-studied intervention may help you cope better with the realities and limitations of chronic illness.

Cannabis and CBD

Cannabis in the form of medical marijuana and cannabidiol (CBD) products have gained considerable popularity as fibromyalgia treatments. Research shows the system affected by cannabis is dysregulated in fibromyalgia.²⁰

That system is called the endocannabinoid system. It plays important roles in multiple functions that are impaired in fibromyalgia, including:²⁰

• Pain processing
• Temperature regulation
• Stress response
• Sleep
• Memory
• Immunity
• Energy metabolism

A growing body of research shows cannabis, CBD, and other cannabis-based medications are promising fibromyalgia treatments. However, it’ll take more studies and longer-term research to know for certain what effect they have.²¹

Supplements

Many people with fibromyalgia use supplements to help control their symptoms. Research into most of them is lacking, though.

Some supplements with research supporting their use include:

• Magnesium²²
• Coenzyme Q10 (CoQ10)²³
• Chlorella green algae
• Acetyl-l-carnitine
• Vitamins C and ⁴

Preliminary research suggests a vegetarian or vegan diet may help ease fibromyalgia symptoms. A low-FODMAP (low-fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet may, as well. This area of study needs a lot more attention and well-designed studies, though.²⁵

Manual Therapy

Manual therapies are those in which a therapist touches your body in order to treat it. Common manual therapies for fibromyalgia include:²⁶

• Massage therapy
• Chiropractic
• Acupuncture/electroacupuncture

You’ll want to work closely with the practitioner so they can learn your pressure tolerance, as too much may exacerbate your symptoms.

 How Cupping Could Relieve Fibromyalgia Symptoms

How to Stay Ahead of Fibromyalgia Pain

Managing your fibromyalgia pain can be a full-time job. It’s important to learn what triggers flares and how to avoid them. The basics are:

• Avoid or manage stress.
• Get plenty of rest.
• Stay active without overdoing it.
• Stick to your treatment regimen.
• Watch for signs of a flare.

Finding the right treatments for you will take time and experimentation. Expect setbacks as you try things that don’t work or cause negative side effects.

When you find a treatment or management tool that works, continue with it—even if it only improves your symptoms a small amount. You may be more likely to find 10 treatments that each alleviate 5% of your symptoms than one treatment that improves them by 50%.

This trial-and-error process can be overwhelming at first. But eventually, spotting and avoiding triggers and staying on track with treatments will become second nature.

Fibromyalgia Pain With Another Chronic Illness

Fibromyalgia often comes with comorbid illnesses—other conditions common in people with fibromyalgia. Comorbid conditions with fibromyalgia include other pain disorders, sleep disorders, anxiety, and fatigue, among others, as detailed below.

Other Pain Conditions

Because fibromyalgia amplifies pain signals, having other conditions that cause pain can be especially debilitating. Many pain conditions are common with fibromyalgia, including:²⁷

• Autoimmune diseases (lupus, rheumatoid arthritis, Sjögren’s syndrome)
• Temporomandibular disorder (TMD)
• Irritable bowel syndrome (IBS)
• Migraine and other headache disorders

Each type of pain you have may require different treatments. For example, an anti-inflammatory that doesn’t help with fibromyalgia pain may be just what you need for the jaw pain of TMD.

Sleep Disorders

People with fibromyalgia often have sleep disorders, which can exacerbate fibromyalgia symptoms. Pain can also make sleep especially difficult. 

Meanwhile, quality sleep is a known way to alleviate fibromyalgia symptoms. That makes identifying and treating sleep disorders crucial. Common ones include:²⁸

• Insomnia
• Obstructive sleep apnea
• Restless legs syndrome (RLS)

If you suspect any of these sleep disorders, talk to a healthcare provider about seeing a sleep specialist. They may order a sleep study (polysomnogram) so they can diagnose sleep disorders.

Other Common Comorbidities

Other conditions that are common in people with fibromyalgia are:²⁷

• Anxiety
• Chronic fatigue syndrome
• Thyroid disease
• Type 2 diabetes
• Multiple chemical sensitivity
• Food and drug sensitivities/intolerances
• Postural orthostatic tachycardia syndrome (POTS)
• Tinnitus (ringing of the ears)

While some comorbid conditions may share symptoms with fibromyalgia, they must be properly diagnosed and treated separately. Watch for new symptoms, especially those unrelated to fibromyalgia, and bring them up with your healthcare provider.

Advocating for Yourself With Invisible Fibromyalgia Pain

Fibromyalgia pain is invisible. While the condition is taken more seriously than it used to be, you can still find some people who don’t believe in the diagnosis, even in the medical profession.

If your healthcare provider is resistant to treating your fibromyalgia, you may have to push for what you want. Sometimes, it’s necessary to find a new provider who’s willing to help you.

In your day-to-day life, you may be around people who think you’re not really sick or that you are making a big deal out of small problems. You’ll have good times and bad times, and your ability to do something one day and not the next may confuse the people around you.

Educating the people closest to you about your illness, its ups and downs, and its broad range of symptoms is important.

 Living With Someone Who Has Fibromyalgia

You may also run into problems at work because of your symptoms and fluctuating health. The Americans With Disabilities Act protects you, so don’t hesitate to request reasonable accommodations to help you keep doing your job.

Summary

Fibromyalgia is a chronic pain condition with abnormal pain types, including hyperalgesia and allodynia. It’s common to have flares and remissions.

The cause of fibromyalgia pain isn’t yet proven, but many nervous system abnormalities have been implicated. These include brain inflammation, small-fiber neuropathy, neurotransmitter dysregulation, abnormal activity and connectivity, and problems with structures called dorsal horn ganglia.

Fibromyalgia treatment often involves medication, exercise, stress management, mental health counseling, cannabis, CBD, supplements, and manual therapies.

Many conditions that can be comorbid with fibromyalgia include TMD, depression, thyroid disease, sleep disorders, and autoimmune conditions.

You may need to educate the people around you about your illness and how it affects you.

 Fibro Fog: Cognitive Dysfunction in Fibromyalgia

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By Adrienne Dellwo
Adrienne Dellwo is an experienced journalist who was diagnosed with fibromyalgia and has written extensively on the topic.