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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
Key points
- Chronic widespread pain (≥3 months) in all 4 quadrants of the body + axial skeleton, with normal investigations
- Associated features: debilitating fatigue, non-restorative sleep, cognitive difficulties ("fibro fog"), and multiple somatic symptoms
- Diagnosis is CLINICAL — investigations should be normal (used to exclude other conditions)
- Management: graded exercise therapy, CBT, sleep hygiene, patient education
- Pharmacological: low-dose amitriptyline (10–25 mg at night), duloxetine, or pregabalin. NOT opioids
Overview
Fibromyalgia is a chronic pain syndrome characterised by widespread musculoskeletal pain, fatigue, non-restorative sleep, and cognitive dysfunction. It is now understood as a disorder of central pain processing (central sensitisation) rather than a peripheral musculoskeletal disease. The 2010/2011 ACR criteria replaced the 1990 tender point examination with symptom-based criteria: widespread pain index (WPI) + symptom severity scale (SSS). All investigations are normal — fibromyalgia is a diagnosis of exclusion that requires ruling out other causes of widespread pain (hypothyroidism, inflammatory arthritis, polymyalgia rheumatica, vitamin D deficiency).
Epidemiology
Fibromyalgia affects approximately 2–5% of the UK population. Female:male ratio is approximately 7:1. Peak onset is 30–50 years. It commonly coexists with other chronic pain conditions (IBS, chronic headache, TMJ dysfunction, chronic pelvic pain) and psychiatric conditions (depression, anxiety, PTSD). Family history is a risk factor.
Clinical Features
Symptoms
Chronic widespread pain: present for ≥3 months, in all 4 quadrants of the body + axial skeleton
Fatigue: severe, debilitating, not improved by rest
Non-restorative sleep: waking unrefreshed despite adequate sleep duration
Cognitive difficulties: "fibro fog" — poor concentration, memory problems, word-finding difficulty
Multiple somatic symptoms: IBS, headaches, paraesthesiae, dizziness, urinary frequency
Mood disturbance: depression and anxiety commonly coexist
Symptoms fluctuate — flares and remissions, often exacerbated by stress, weather change, poor sleep
Signs
Multiple tender points on palpation (though formal tender point examination no longer required for diagnosis)
Normal neurological examination
Normal joint examination (no synovitis, no effusions)
If joint swelling, inflammatory signs, or neurological deficit present: investigate for alternative diagnosis
Investigations
First-line
Bloods to exclude differentialsFBC, ESR/CRP (normal in fibromyalgia — raised suggests inflammatory disease), TFTs, calcium, vitamin D, U&Es, LFTs, glucose/HbA1c
Second-line
Autoimmune screenANA, RF, anti-CCP — only if clinical features suggest autoimmune disease. Do NOT order routinely (false positives cause confusion)
Specialist
No specific diagnostic testFibromyalgia is a CLINICAL diagnosis — all investigations should be normal. Excessive investigation is harmful (anxiety, medicalisation)
1
Education and self-management
- Explain the diagnosis clearly: real pain, central sensitisation, not imagined, not progressive/destructive
- Set realistic expectations: aim for improved function, not complete pain elimination
- Self-management strategies: pacing, stress management, sleep hygiene
2
Non-pharmacological (first-line per NICE NG193)
- Graded exercise therapy: aerobic exercise starting low and increasing gradually — strongest evidence base
- Psychological therapy: CBT or acceptance and commitment therapy (ACT)
- Sleep hygiene and management
- Multidisciplinary pain management programme for severe/refractory cases
3
Pharmacological
- Low-dose amitriptyline: 10–25 mg at night (off-label) — improves pain, sleep, and fatigue
- Duloxetine 60 mg OD: SNRI — helpful if comorbid depression
- Pregabalin 75–300 mg BD: may help pain and sleep (gabapentinoid)
- NICE NG193: do NOT offer opioids, paracetamol, NSAIDs, antipsychotics, or benzodiazepines for chronic primary pain (including fibromyalgia)
Complications
- Depression and anxiety: Very common comorbidities — screen and treat
- Disability and work absence: Significant functional impairment
- Iatrogenic harm: Polypharmacy (opioids, gabapentinoids), excessive investigation, unnecessary referrals
- Sleep disorders: Obstructive sleep apnoea, restless legs — may coexist and worsen fibromyalgia
UKMLA Exam Tips
- 1Chronic widespread pain + fatigue + non-restorative sleep + cognitive fog + ALL NORMAL investigations = fibromyalgia
- 2Diagnosis of EXCLUSION — must rule out hypothyroidism, vitamin D deficiency, inflammatory arthritis, PMR
- 3ESR/CRP normal in fibromyalgia — if raised, think alternative diagnosis
- 4NICE NG193: do NOT offer opioids or paracetamol for chronic primary pain. Exercise and psychology first-line
- 5Amitriptyline 10–25 mg at night is the most commonly used pharmacological agent
- 6Fibromyalgia can coexist with other conditions (e.g. RA + fibromyalgia) — treat both
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