Treatment of Sleep Disturbances in Fibromyalgia

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Michele Thomas, PharmD, BCPP

This session can be purchased in CPNP University

Fibromyalgia is a medical syndrome associated with widespread pain and sleep problems leading to chronic daytime fatigue. The combination of pain and sleep disturbances is a double-edged sword as pain makes sleep more difficult and sleep deprivation exacerbates pain. Christopher Herndon, PharmD, CPE, FASHP shared his expertise at the CPNP 2018 meeting in his presentation titled Painfully Sleepless: Treatment of Sleep Disorders in Fibromyalgia. Dr. Herndon is a professor with the Southern Illinois University Edwardsville (SIUE) School of Pharmacy and treats chronic pain patients at a multidisciplinary family medicine clinic.

Up to 90% of patients with fibromyalgia report problems with sleep1, and sleep disturbances in patients with fibromyalgia are slightly different than sleep disturbances in the general population2. Patients with fibromyalgia tend to have more nighttime awakenings and arousals compared to patients with primary insomnia.

Dr. Herndon described several behavioral treatment modalities for insomnia associated with fibromyalgia. Cognitive behavioral therapy (CBT), sleep hygiene counseling, time in bed reduction, and elimination of daytime napping are examples. Out of these, as described by Dr. Herndon, CBT is associated with the most significant improvement in sleep3. Physical treatment modalities include manual therapy, hydrotherapy, acupuncture, and Tai Chi.

Pharmacotherapy directed at insomnia in the setting of fibromyalgia includes the use of cyclobenzaprine, amitriptyline, gabapentin, pregabalin, and trazodone. Interestingly, the traditional hypnotics such as the benzodiazepines are not well studied for patients with fibromyalgia. Dr. Herndon explained that the selection of the best medication for a patient with sleep disturbances in fibromyalgia is difficult as there are few well controlled studies in this population. Dr. Herndon reviewed the limited data and explained the European guidelines recommend cyclobenzaprine, amitriptyline, and pregabalin as treatments of choice for sleep disturbances in patients with fibromyalgia4.

Take Home Points

  • In patients with fibromyalgia, sleep disturbances contribute to pain and pain negatively impacts sleep.
  • CBT has been shown to be a non-pharmacologic modality to help with sleep in patients with fibromyalgia. 
  • There is limited data on drug therapy for treating sleep disturbances in patients with fibromyalgia.
  • Guidelines recommend cyclobenzaprine, amitriptyline, and pregabalin as best options for treating sleep problems in patients with fibromyalgia. 

References

  1. White KP, Speechley M, Harth M, Ostbye T. The London Fibromyalgia Epidemiology Study: Comparing the demographic and clinical characteristics in 100 random community cases of fibromyalgia versus controls. J Rheumatol. 1999;26:1577–1585.
  2. Roth T, Bhadra-Brown P, Pitman VW, Roehrs TA, Resnick EM.  Characteristics of disturbed sleep in patients with fibromyalgia compared with insomnia or with pain-free volunteers. Clin J Pain.  2016;32:302–307.
  3. Martínez MP, Miró E, Sánchez AI, et al, Cognitive-behavioral therapy for insomnia and sleep hygiene in fibromyalgia: a randomized controlled trial. J Behav Med. 2014;37:683–697.
  4. Macfarlane GJ, Kronisch C, Dean LE, et al.  EULAR revised recommendations for the management of fibromyalgia. Annals of the Rheumatic Diseases 2017;76:318-328.
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