Differential diagnosis of fibromyalgia
- Don L Goldenberg, MD
Don L Goldenberg, MD
- Section Editor — Pain Disorders in Rheumatology
- Emeritus Professor of Medicine, Tufts University School of Medicine
- Affiliate Assistant, Rheumatology Division, Oregon Health Science University
- Affiliate Instructor, School of Nursing Oregon Health Sciences University
Fibromyalgia (FM) is a common cause of chronic widespread musculoskeletal pain, often accompanied by fatigue, cognitive disturbance, psychiatric symptoms, and multiple somatic symptoms. Despite the presence of soft tissue pain affecting the muscles, ligaments, and tendons, fibromyalgia itself is not associated with evidence of tissue inflammation, and a cardinal feature of FM is that the pain is not explained by another rheumatic or systemic disorder.
Explicit in the definition of FM is the exclusion of other conditions that can present with widespread pain. However, FM is often associated with other conditions that may cause musculoskeletal pain, disruption of sleep, or psychiatric symptoms; features of these conditions may also mimic FM, and the presence of such disorders should be considered in the diagnostic evaluation.
This topic will review the differential diagnosis of FM in adults. The clinical manifestations, diagnosis, and treatment of this condition in adults, as well as FM in children and adolescents, are discussed in detail elsewhere. (See "Clinical manifestations and diagnosis of fibromyalgia in adults" and "Approach to the patient with myalgia" and "Initial treatment of fibromyalgia in adults" and "Treatment of fibromyalgia in adults not responsive to initial therapies" and "Fibromyalgia in children and adolescents: Clinical manifestations and diagnosis" and "Fibromyalgia in children and adolescents: Treatment and prognosis".)
APPROACH TO THE DIFFERENTIAL DIAGNOSIS
The differential diagnosis of fibromyalgia (FM) is large, given the number of conditions that can present with signs or symptoms of FM, such as pain, fatigue and sleep disturbance, and symptoms of cognitive dysfunction and psychiatric disease . However, the diagnosis of FM and the exclusion of other alternative diagnoses included in the differential diagnosis can generally can be achieved based upon a thorough history and physical examination, and requires only limited laboratory testing (table 1 and algorithm 1). The diagnostic approach to FM is described in detail separately. (See "Clinical manifestations and diagnosis of fibromyalgia in adults", section on 'Diagnosis'.)
Fibromyalgia is diagnosed when characteristic features are present and other medical conditions have been excluded as the cause of the patient's symptoms. The confidence that each clinician has in making this decision is related to their level of experience, particularly in evaluating rheumatic disorders. Features of each of the major conditions in the differential and potentially confounding factors to consider in the evaluation can be identified and are summarized in the table (table 2).
- Clauw DJ. Fibromyalgia: a clinical review. JAMA 2014; 311:1547.
- Aaron LA, Buchwald D. Chronic diffuse musculoskeletal pain, fibromyalgia and co-morbid unexplained clinical conditions. Best Pract Res Clin Rheumatol 2003; 17:563.
- Dinerman H, Goldenberg DL, Felson DT. A prospective evaluation of 118 patients with the fibromyalgia syndrome: prevalence of Raynaud's phenomenon, sicca symptoms, ANA, low complement, and Ig deposition at the dermal-epidermal junction. J Rheumatol 1986; 13:368.
- Andersson ML, Svensson B, Bergman S. Chronic widespread pain in patients with rheumatoid arthritis and the relation between pain and disease activity measures over the first 5 years. J Rheumatol 2013; 40:1977.
- Segal BM, Pogatchnik B, Henn L, et al. Pain severity and neuropathic pain symptoms in primary Sjögren's syndrome: a comparison study of seropositive and seronegative Sjögren's syndrome patients. Arthritis Care Res (Hoboken) 2013; 65:1291.
- Fitzcharles MA, Boulos P. Inaccuracy in the diagnosis of fibromyalgia syndrome: analysis of referrals. Rheumatology (Oxford) 2003; 42:263.
- Clark S, Tindall E, Bennett RM. A double blind crossover trial of prednisone versus placebo in the treatment of fibrositis. J Rheumatol 1985; 12:980.
- Fernandez G, Spatz ES, Jablecki C, Phillips PS. Statin myopathy: a common dilemma not reflected in clinical trials. Cleve Clin J Med 2011; 78:393.
- Tomaszewski M, Stępień KM, Tomaszewska J, Czuczwar SJ. Statin-induced myopathies. Pharmacol Rep 2011; 63:859.
- Goldenberg DL. Do infections trigger fibromyalgia? Arthritis Rheum 1993; 36:1489.
- Steere AC, Taylor E, McHugh GL, Logigian EL. The overdiagnosis of Lyme disease. JAMA 1993; 269:1812.
- Cruz BA, Catalan-Soares B, Proietti F. Higher prevalence of fibromyalgia in patients infected with human T cell lymphotropic virus type I. J Rheumatol 2006; 33:2300.
- Feder HM Jr, Johnson BJ, O'Connell S, et al. A critical appraisal of "chronic Lyme disease". N Engl J Med 2007; 357:1422.
- Wormser GP, Weitzner E, McKenna D, et al. Long-Term Assessment of Fibromyalgia in Patients with Culture-Confirmed Lyme Disease. Arthritis Rheumatol 2014.
- Ribeiro LS, Proietti FA. Interrelations between fibromyalgia, thyroid autoantibodies, and depression. J Rheumatol 2004; 31:2036.
- Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D in patients with persistent, nonspecific musculoskeletal pain. Mayo Clin Proc 2003; 78:1463.
- Lyman D. Undiagnosed vitamin D deficiency in the hospitalized patient. Am Fam Physician 2005; 71:299.
- Block SR. Vitamin D deficiency is not associated with nonspecific musculoskeletal pain syndromes including fibromyalgia. Mayo Clin Proc 2004; 79:1585.
- Daniel D, Pirotta MV. Fibromyalgia--should we be testing and treating for vitamin D deficiency? Aust Fam Physician 2011; 40:712.
- Martínez-Lavin M, López S, Medina M, Nava A. Use of the leeds assessment of neuropathic symptoms and signs questionnaire in patients with fibromyalgia. Semin Arthritis Rheum 2003; 32:407.
- Giannoccaro MP, Donadio V, Incensi A, et al. Small nerve fiber involvement in patients referred for fibromyalgia. Muscle Nerve 2014; 49:757.
- Caro XJ, Winter EF. Evidence of abnormal epidermal nerve fiber density in fibromyalgia: clinical and immunologic implications. Arthritis Rheumatol 2014; 66:1945.
- Üçeyler N, Zeller D, Kahn AK, et al. Small fibre pathology in patients with fibromyalgia syndrome. Brain 2013; 136:1857.
- Simms RW, Goldenberg DL. Symptoms mimicking neurologic disorders in fibromyalgia syndrome. J Rheumatol 1988; 15:1271.
- Watson NF, Buchwald D, Goldberg J, et al. Neurologic signs and symptoms in fibromyalgia. Arthritis Rheum 2009; 60:2839.
- Hong CZ. Treatment of myofascial pain syndrome. Curr Pain Headache Rep 2006; 10:345.
- Tunks E, McCain GA, Hart LE, et al. The reliability of examination for tenderness in patients with myofascial pain, chronic fibromyalgia and controls. J Rheumatol 1995; 22:944.
- Wolfe F, Simons DG, Fricton J, et al. The fibromyalgia and myofascial pain syndromes: a preliminary study of tender points and trigger points in persons with fibromyalgia, myofascial pain syndrome and no disease. J Rheumatol 1992; 19:944.
- Basford JR, An KN. New techniques for the quantification of fibromyalgia and myofascial pain. Curr Pain Headache Rep 2009; 13:376.
- Lucas N, Macaskill P, Irwig L, et al. Reliability of physical examination for diagnosis of myofascial trigger points: a systematic review of the literature. Clin J Pain 2009; 25:80.
- Borg-Stein J. Treatment of fibromyalgia, myofascial pain, and related disorders. Phys Med Rehabil Clin N Am 2006; 17:491.
- Fernández-de-Las-Peñas C, Alonso-Blanco C, Cuadrado ML, et al. Myofascial trigger points and their relationship to headache clinical parameters in chronic tension-type headache. Headache 2006; 46:1264.
- Gerwin RD. Diagnosing fibromyalgia and myofascial pain syndrome: a guide. J Fam Pract 2013; 62:S19.
- Wigley R. Can fibromyalgia be separated from regional pain syndrome affecting the arm? J Rheumatol 1999; 26:515.
- Aaron LA, Burke MM, Buchwald D. Overlapping conditions among patients with chronic fatigue syndrome, fibromyalgia, and temporomandibular disorder. Arch Intern Med 2000; 160:221.
- Fukuda K, Straus SE, Hickie I, et al. The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group. Ann Intern Med 1994; 121:953.
- Goldenberg DL, Simms RW, Geiger A, Komaroff AL. High frequency of fibromyalgia in patients with chronic fatigue seen in a primary care practice. Arthritis Rheum 1990; 33:381.
- Cole JA, Rothman KJ, Cabral HJ, et al. Migraine, fibromyalgia, and depression among people with IBS: a prevalence study. BMC Gastroenterol 2006; 6:26.
- Caldarella MP, Giamberardino MA, Sacco F, et al. Sensitivity disturbances in patients with irritable bowel syndrome and fibromyalgia. Am J Gastroenterol 2006; 101:2782.
- Kurland JE, Coyle WJ, Winkler A, Zable E. Prevalence of irritable bowel syndrome and depression in fibromyalgia. Dig Dis Sci 2006; 51:454.
- Amital D, Fostick L, Polliack ML, et al. Posttraumatic stress disorder, tenderness, and fibromyalgia syndrome: are they different entities? J Psychosom Res 2006; 61:663.
- Aaron LA, Buchwald D. A review of the evidence for overlap among unexplained clinical conditions. Ann Intern Med 2001; 134:868.
- Almansa C, Rey E, Sánchez RG, et al. Prevalence of functional gastrointestinal disorders in patients with fibromyalgia and the role of psychologic distress. Clin Gastroenterol Hepatol 2009; 7:438.
- Tietjen GE, Brandes JL, Peterlin BL, et al. Allodynia in migraine: association with comorbid pain conditions. Headache 2009; 49:1333.
- Meeus M, Ickmans K, Struyf F, et al. What is in a name? Comparing diagnostic criteria for chronic fatigue syndrome with or without fibromyalgia. Clin Rheumatol 2016; 35:191.
- APPROACH TO THE DIFFERENTIAL DIAGNOSIS
- ARTHRITIS AND SYSTEMIC RHEUMATIC DISEASES
- MUSCLE DISEASE AND MYALGIA
- INFECTIOUS, METABOLIC, AND NEUROLOGIC DISORDERS
- REGIONAL SOFT TISSUE PAIN
- Myofascial pain syndromes
- Tendinitis and bursitis
- OTHER DISORDERS THAT MAY OVERLAP WITH FM
- Functional somatic syndromes
- Chronic fatigue syndrome (systemic exertion intolerance disease)
- Psychiatric disorders
- Sleep disturbance
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS