Hundreds if not thousands of articles have been written trying to explain the causes of Fibromyalgia. Originally, Fibromyalgia was thought to be a psychiatric illness, but more recently, research has shown that there are physical changes in individuals with Fibromyalgia that indicate a viral illness. The depression, memory loss, chronic fatigue, mental confusion, muscle and joint aches and pains that so many people with this disease suffer from are actually spread like the common cold! In fact, my quest into the origins of this disease began when it almost ended my medical practice.
I first began to feel the effects of Fibromyalgia/chronic fatigue in 1986. Prior to its onset, I was leading a busy and satisfying life, feeling great and working hard.
My Fibromyalgia and Chronic Fatigue Symptoms started gradually. I began to feel very tired. I made all kinds of excuses for it. I was now in my forties and thought maybe I was just getting old. I would go to sleep right after work, waking up only to have dinner, and then go right back to sleep for the night. In the morning, the cycle would start all over. Eventually, I had a couch put in my office so I could sleep between surgery and office hours. I would just literally pass out for about two hours every day in the middle of the workday. I had very little time for my family, for myself, or for anything except sleeping, eating and going to work. It was a complete reversal of my previous life, and nothing like I had thought my life would be.
To make matters worse, new symptoms began developing within months. I started to get frequent headaches, night sweats, and irritable bowel. In addition, my muscles and joints started to feel heavy, weak and sore. For me, however, the fatigue was the dominant symptom. It was taking an enormous toll on my life. One particularly stressful incident made me realize that my constant state of exhaustion had reached a dangerous - and potentially fatal - level.
One winter night about 6 p.m., I had taken my usual two-hour nap and finished my office hours. I was driving home, and passed out at the wheel. When I woke up, I had veered into the center median and was zipping along at about 60 MPH, heading for a cement culvert. I got the car stopped just in time, but the shocking near-accident was a defining moment for me. I realized without question that I had to do something about my condition.
Initially, I thought my symptoms were the result of food allergies. In truth, food allergies do play a huge role in Fibromyalgia. Rather than being a cause of the condition, however, many allergies actually develop as a result of the viral infections. At that point, I had done quite a bit of allergy research, beginning in 1972 with my Otolaryngology (ENT) residency at the University of Pittsburgh.
So changing my diet did help alleviate the initial symptoms of Fibromyalgia and chronic fatigue, but there was still something missing. After my near-accident, I became aggressive in looking for anything and everything that might help me discover the cause of my ongoing symptoms.
By Victor Rosenfeld, MD
A 54-year-old woman with widespread pain, fatigue, and insomnia presents to the healthcare provider’s office with complaints of excessive daytime drowsiness. The patient noted that she developed chronic widespread pain and fatigue following routine gynecologic surgery to treat endometriosis in 1993. Since that time, she has been seen by numerous specialists, including rheumatologists, neurologists, urologists, pain specialists, and gastroenterologists.
Past Medical History
The patient was initially diagnosed and treated for systemic lupus erythematosus, although testing was inconclusive and she has never developed any classic manifestations of the disease. She initially rated her pain on a visual analog scale (VAS) as 9 of 10, but now says that it is about 4 of 10. She has many syndromes associated with fibromyalgia (FM), including irritable bowel syndrome, irritable bladder, migraine headaches, fatigue, temporomandibular joint (TMJ) pain, restless leg syndrome (RLS), non-refreshing, nonrestorative sleep, and myofascial pain.
A neurologist has managed the patient’s migraines with the use of intramuscular lidocaine and corticosteroid injections. To stop the migraine, the patient takes a triptan agent, usually with good success. Her past medical history is negative for cervical spinal trauma or psychosexual trauma.
The patient’s medication history includes failed treatment with duloxetine (Cymbalta) and milnacipran (Savella). Pregabalin (Lyrica) and gabapentin therapy produced weight gain and somnolence. Trazodone therapy caused excessive daytime sleepiness, zolpidem (Ambien) caused some complex sleep behaviors, and diazepam caused depression. Pramipexole (Mirapex) has helped her RLS and pain. Benadryl, which helps with sleep, exacerbates her RLS.
The patient’s current medication history includes tramadol 100 mg per night (Ultram); acetaminophen and hydrocodone (Vicodin), used sparingly; pramipexole 1.5 mg per night; clonazepam 0.5 mg per night (Klonopin); sertraline 25 mg/day (Zoloft); Tylenol PM, and zolpidem as needed.
The patient is a busy executive for a nonprofit organization who neither smokes nor drinks. She has a brother diagnosed with obstructive sleep apnea (OSA), but no family history of FM or RLS.
On presentation, the patient complains of excessive daytime drowsiness. Epworth Sleepiness Scale is elevated at 21. Fatigue Severity Scale is elevated at 50. The patient admits to problems with drowsiness during the day that affects her ability to function, including falling asleep at work and meetings, having near car accidents, and having to take frequent naps during the day.
Circadian rhythm is quite variable due to her work schedule and multiple sleep issues, but she usually goes to bed around 1:00 am, wakes up at 5:30 am, and uses sleep aids. She has been told that she stops breathing at night. She has gastroesophageal reflux, and wakes up with headaches. Her RLS is managed well with pramipexole 1.5 mg taken at bedtime and she wears a bite guard for her TMJ. There is no obvious evidence of hypersomnia or narcolepsy. Sleep hygiene is poor. Table 1 provides results from the physical examination and Figure 1 illustrates the results of the sleep hypnogram.
Diagnosis and Treatment Plan
Based on the results of physical examination and polysomnography (PSG), the patient was diagnosed with FM, RLS, insomnia, and severe OSA. The patient was started on a regimen of sodium oxybate (Xyrem) 3 g per night, given in divided doses, to help treat the pain, fatigue, and sleep problems associated with FM. Although not FDA approved for this indication, sodium oxybate has been shown in large Phase III trails to reduce pain and fatigue, and improve sleep and function in patients with FM.1
Since the patient is intolerant to continuous positive airway pressure (CPAP) devices, the severe OSA was treated with an oral appliance therapy with mandibular advancement. The patient was continued on pramipexole for RLS and told to avoid Benadryl. The patient was instructed on good sleep hygiene practices and was given benzodiazepine sparingly to treat insomnia.
The oral appliance therapy was effective for OSA in this patient, as evidenced by nocturnal pulse oximetry findings and resolution of sleepiness, but her TMJ was exacerbated. It was recommended that the patient consider turbinate surgery and retrial of CPAP (with or without sodium oxybate) to assist with pain and sleep. Her RLS remained and was treated with pramipexole and avoidance of Benadryl. Her insomnia improved, but sleep hygiene remains a persistent issue. The patient had a significant reduction in fatigue and nonrestorative sleep while on moderate doses of sodium oxybate (3 mg/night); higher doses produced increase side effects that outweighed any additional sleep benefit.
Last updated on: September 20, 2011