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An Approach to Addressing Treatment-Resistant Fibromyalgia

Fibromyalgia is characterized by widespread musculoskeletal pain due to abnormal pain processing and is frequently accompanied by fatigue, as well as sleep, memory, and mood dysfunction. It’s considered to be a diagnosis of exclusion, meaning that providers should only diagnose a patient with fibromyalgia after having thoroughly evaluated the patient for other conditions that could be causing their symptoms. After all other relevant conditions, such as autoimmune conditions, thyroid dysfunction, and chronic infection, have been deemed less- or unlikely, treatment of fibromyalgia typically consists of pharmacotherapeutic symptom control. This could include antidepressants, muscle relaxants, and some pain relievers, all of which are frequently prescribed to help relieve the pain and fatigue associated with the disorder. But what happens when we’ve ruled out other diagnostic possibilities and we’ve sought to address our patients’ health in the conventional manner, and yet they experience little to no improvement? What should our next steps be? I’d like to submit to you that at this point, if not before, it’s crucial that we take a comprehensive approach in order to identify factors that can cause or aggravate fibromyalgia symptoms, such as lifestyle factors, micronutrient deficiencies, gut health, hormones, and mental-emotional factors, and then address any and all areas of dysfunction.

Does Lifestyle (Exercise, Sleep, Nutrition) Play A Role in Fibromyalgia?

Lifestyle plays a critical role in fibromyalgia symptomatology. For example, physical activity is relevant to fibromyalgia in that both aerobic exercise and strength training have been demonstrated to reduce fibromyalgia-related symptoms, including pain, fatigue, and depression and to improve quality of life.[1]

Research also demonstrates that disordered sleep may alter our pain perception, which is very relevant considering the abnormalities in pain processing that characterize fibromyalgia syndrome.[2] If our patients chronically obtain insufficient quantities and quality of sleep, they are more likely to exhibit fibromyalgia symptoms such as myalgia, tenderness, and fatigue.

Although very few well-designed studies have been conducted on the topic, nutrition is also crucial in addressing treatment-resistant fibromyalgia. The research that has been conducted is promising, suggesting that hypocaloric, low-FODMAP, and plant-based diets may be beneficial in improving quality of life, quality of sleep, anxiety, depression, and inflammatory biomarkers in fibromyalgia.[3]

Regardless of the type of diet that is most appropriate for our patients, it’s important that they consume diets comprised of a variety of micronutrients so as to avoid vitamin and/or mineral deficiency. Evaluating patients for micronutrient deficiencies and correcting them when present is important in improving treatment-resistant fibromyalgia. As an example, many fibromyalgia patients are deficient in magnesium.[4] Intravenous magnesium therapy has been found to play a crucial role in alleviating pain in a number of conditions.[5]

Increasing dietary intake of a wide variety of micronutrients is important, but because (as we’ll see) fibromyalgia is characterized by impaired gastrointestinal health, intravenous administration may be a superior means of replenishing micronutrients. This is because IV nutrients bypass the gut and therefore do not require optimal digestion and absorption.

To learn more about incorporating IV nutrient therapy into your practice to address fibromyalgia and other concerns, click here.

What Role Does Gut Health Play in Fibromyalgia?

Recent research has demonstrated that the gastrointestinal microbiomes of women with fibromyalgia were markedly different from those of healthy controls. In one study, women who had been diagnosed with fibromyalgia were found to have overgrowth of certain strains of bacteria and insufficient amounts or absence of beneficial bacteria compared to healthy controls.[6] Researchers determined that the variations in microbiome composition were fibromyalgia-related and were not due to other factors that are known to influence the microbiome, such as diet, medication, physical activity, and age.

As a result of this particular study, researchers were able to identify a positive correlation between the degree of gastrointestinal dysbiosis and the severity of fibromyalgia symptoms. In other words, study participants whose microbiomes were more abnormal reported increased symptomatology, including more pain, fatigue, and cognitive difficulties.

The results of this and other studies [7] suggest that by analyzing our patients’ gastrointestinal health and microbiome composition and correcting dysbiosis when present, we may see improvements in fibromyalgia symptomatology.

What Role Do Reproductive Hormones Play In Fibromyalgia?

Fibromyalgia disproportionately affects women. Although we aren’t certain of all of the mechanisms involved, we believe that this is because our sex hormones (particularly estrogen) have important effects on our sensitivity to pain. Specifically, estrogen appears to modulate our pain sensitivity; therefore, women tend to report an increase in fibromyalgia-related pain at times when estrogen levels are low or declining, such as during the follicular phase of the menstrual cycle, as well as the post-natal and peri-menopausal periods. On the other hand, symptoms appear to improve for many patients during the luteal phase and during pregnancy.

As a part of a comprehensive approach to patients with treatment-resistant fibromyalgia, I’ve found evaluating and optimizing reproductive hormone function by providing endocrine system support to be extremely beneficial.

The Importance Of A Comprehensive Approach

In conclusion, when our patients don’t respond to our preliminary treatment approach, it’s oftentimes necessary to take a step back and re-evaluate each patient as a unique, complex individual. This could include looking at lifestyle factors like exercise, sleep, and diet; micronutrient status; gastrointestinal health and microbiome composition; reproductive and other hormone status; stress levels, mental-emotional state, and trauma history; and much more. When we take a more comprehensive look at our patients’ health, we are more likely to elucidate causative and contributing factors to their health concerns and we’re better able to help them optimize their physical and mental health. When we do these things, we live up to our calling as healthcare professionals and as healers.


  1. Busch AJ, Webber SC, Brachaniec M, et al. Exercise therapy for fibromyalgia. Curr Pain Headache Rep. 2011;15(5):358–367. doi:10.1007/s11916-011-0214-2

  2. Choy EH. The role of sleep in pain and fibromyalgia. Nat Rev Rheumatol 2015;11:513–20. 10.1038/nrrheum.2015.56

  3. Silva AR, Bernardo A, Costa J, et al. Dietary interventions in fibromyalgia: a systematic review. Ann Med. 2019;51(sup1):2-14. doi: 10.1080/07853890.2018.1564360.

  4. Ali A, Njike VY, Northrup V, et al. Intravenous micronutrient therapy (Myers' Cocktail) for fibromyalgia: a placebo-controlled pilot study. J Altern Complement Med. 2009;15(3):247–257. doi:10.1089/acm.2008.0410

  5. Anand A. Role of magnesium in alleviating pain: newer insights. J Pain Symptom Manage. 2000 Jul;20(1):1-2.

  6. Minerbi A, Gonzalez E, Brereton NJ, et al. Altered microbiome composition in individuals with fibromyalgia. Pain. 2019 Jul 2. doi: 10.1097/j.pain.0000000000001640.

  7. Roman P, Carrillo-Trabalón F, Sánchez-Labraca N, et al. Are probiotic treatments useful on fibromyalgia syndrome or chronic fatigue syndrome patients? A systematic review. Benef Microbes. 2018 Jun 15;9(4):603-611. doi: 10.3920/BM2017.0125.


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