Understanding fibromyalgia
Fibromyalgia is a commonly diagnosed condition: the third most frequent musculoskeletal condition (1) and can have a big impact on people’s daily life. It is characterised by a collection of symptoms often including (but not exclusive to) widespread pain, sleep issues, physical exhaustion, and cognitive difficulties (2) (see signs and symptoms section for further details).
In 2011 the charity Fibromyalgia Action UK suggested that fibromyalgia is seen in around 2% of the population, affecting more women than men (at a 9:1 ratio), with around 14,000 new diagnoses each year (3).
However, a more recent report from 2019 / 2020 detailing surveys of healthcare professionals carried out across the UK, to profile the healthcare services available to people with fibromyalgia, suggested that the condition affects around 2.5 million people in the UK, which according to 2022 figures is closer to 3% of the population (4).
From pooled qualitative data of the surveys and those of people with fibromyalgia, three themes concerning the condition and healthcare availability emerged:
- A troublesome label
- A heavy burden
- A low priority
The survey also reported that tools designed to support the fulfilment of fibromyalgia diagnostic criteria were used inconsistently by clinicians diagnosing fibromyalgia, raising the question of whether diagnoses are accurate (4). Although more accurate diagnostic criteria have improved diagnosis, a considerable proportion of doctors still fail to recognise fibromyalgia (1).
3 out of 10 GP’s surveyed also reported not diagnosing fibromyalgia, with reasons being:
- Lack of skill and confidence
- Uncertainty about whether fibromyalgia is a distinct condition
- Opinion that the diagnosis may not help patients.
This highlights the challenges which may be faced with anyone experiencing fibromyalgia, however there are herbal and holistic solutions which can be of support.
How does fibromyalgia work?
Although the mechanism by which fibromyalgia develops is not fully understood, it is often associated with an altered stress response system (5), and the symptom picture seems to be comprised of three systems (6):
- Musculoskeletal system (muscles and bones)
- Neuroendocrine system (nervous system and hormones)
- Psychological distress (including anxiety and depression)
Research has identified two possible mechanisms for fibromyalgia:
- Serotonin deficiency in the central nervous system (CNS) (3, 7), this results in imbalances in substance P, which acts as a neurotransmitter sending pain signals to the brain.
- Inadequate regulation of thyroid hormone (ITHR), which may contribute to the chronic widespread pain and tenderness experienced by people with fibromyalgia. This is suggested to be due to the impact of ITHR on metabolic processes which influence the processes involved in the antinociceptive (pain reducing) signalling system between the brainstem and spinal cord. This can lead to (7):
- Spontaneous and ongoing pain
- Tenderness (lowered pain threshold to mechanical pain)
- Hyperalgesia (increased responsiveness to noxious stimuli)
Substance P is often found to be high in people with fibromyalgia, which may also account for the increased sensitivity to pain. Thyroid hormone inhibits substance P synthesis and secretion in parts of the CNS. The increase in substance P found in fibromyalgia patients may be linked to ITHR.
Serotonin is involved in antinociceptive pathways in the nervous system. Nociception refers to the detection of painful stimuli, which is fed back to the brain. Serotonin stimulates the secretion of opiates which inhibit transmission of pain signals to the brain, by blocking release of pain signalling neurotransmitters, such as substance P. The same neurons which secrete serotonin in antinociceptive pathways, also secrete norepinephrine / noradrenalin (NE), and serotonin secretion is dependent on NE secretion.
It is thought that ITHR reduces the synthesis and secretion of NE in the brain. This may have a knock-on effect down the antinociceptive system and is one theory which hypothesises why fibromyalgia involves such high pain sensitivity (7), due to serotonin deficiency, altered stress responses, which may also account for thyroid hormone imbalances, and high substance P levels.
Factors which may contribute to this ITHR / hypometabolism include (7):
- Hypothyroidism or partial cellular resistance to thyroid hormones
- Nutritional deficiencies (potentially from diet)
- Low physical fitness level
- Metabolism-impeding drugs
- Hypothalamus / stress response system imbalances
Understanding the root
There are various theories on the underlying root cause for fibromyalgia, although there is usually not one clear cause, and tends to be unique to each person. Some of the possible triggers for its onset include (1, 3):
- Genetic predisposition
- Physical trauma (e.g. a fall or car accident)
- Viral infection
- Hormonal / metabolic imbalances
- Surgery
- Muscular issues
- Personal experiences
- Emotional-cognitive factors
- Mind-body relationship and biopsychosocial ability to cope with stress
There can also be no obvious trigger, or, being a complex condition, a combination of factors. With or without a specific trigger, the mechanism of how fibromyalgia develops from any avenue remains unclear (3), and the complexity of the condition makes a multi model treatment approach necessary.
Signs and symptoms
The main symptom of fibromyalgia is widespread chronic pain, which can include axial pain and tenderness at anatomical tender points.
Other symptoms of fibromyalgia include (8, 7):
- Increased sensitivity to pain
- Fatigue
- Muscle stiffness
- Headaches
- Sleep difficulties (for example getting to sleep or staying asleep)
- Cognitive dysfunction, such as challenges with mental processes (known as “fibro-fog”), difficulty concentrating or remembering things
- Paresthesias (tingling, burning, prickling sensations or numbness of skin)
- Exercise intolerance
- Irritable bowel syndrome (IBS), a digestive condition that causes stomach pain and bloating
- Feelings of frustration, worry or low mood
- Anxiety
- Depression
- The symptoms of fibromyalgia are changeable – for example, they can sometimes suddenly improve or get worse.
Herbal solutions
Although fibromyalgia is classified as a musculoskeletal condition, it involves components of autoimmunity, metabolic / hormonal imbalances, and altered stress response, making the scope for holistic herbal treatment far wider than simply looking at the musculoskeletal system, joints, and pain. Treatment would also constitute support for the immune system, hormonal and metabolic system, and nervous system, as well as anodyne herbs for symptomatic relief of pain. Providing adaptogenic and adrenal tonic herbs which restore healthy immune function, stress responses, and will thereby support hormone balance, calming nervous system tonics to restore nervous system function, better sleep, and help manage stress.
The support provided by herbal medicines and lifestyle may help to alleviate the impact of fibromyalgia on daily life, such as reducing pain and fatigue, improving sleep and cognitive function. However, due to the complexity of the condition it may be necessary to sustain treatment over a prolonged period. Seeking guidance of a professional herbalist would be helpful in tailoring support specifically to you. You can find details of herbalists on our resources page.
Adrenal support
Rehmannia acts as a tonic for the adrenal glands, which are involved in stress responses, it can help recovery from prolonged stress, and to regulate stress responses. This makes it a helpful herb in the case of fibromyalgia, especially when there seems to be an imbalance in the stress response system, it will regulate the function and assist in increasing overall vigour and vitality.
Rehmannia also acts as an adaptogen, helping to restore healthy responses to stress, improving the body’s resilience to stress and reducing the potential for detrimental impact of stress on the body.
Licorice is a fantastic adrenal tonic, providing valuable support to restore healthy function of stress responses. It is beneficial for regulating the function of the HPA axis (hypothalamus-pituitary-adrenal axis), which is the body’s stress response system (9). This will be supportive in cases of fibromyalgia where stress seems to be an underlying factor, and stress responses out of kilter.
Adaptogenic herbs
Astragalus is an adaptogenic herb which helps to improve the healthy function of the immune system. It seems to be particularly beneficial in conditions which involve post-viral type fatigue, and so may help in managing the fatigue associated with fibromyalgia, especially when onset seemed to follow a viral infection.
Rhodiola is a herb with adaptogenic properties, assisting in re-establishing balance in the body’s stress response system (HPA-axis). This herb is particularly helpful for improving physical and mental performance, concentration, and memory, which can be beneficial in fibromyalgia where physical fatigue and brain fog are factors. The herb is also known to improve low mood (moderately low mood), and improve the quality of sleep, making it an ideal herb for helping to support the nervous system which is often affected by fibromyalgia and can manifest in depression and sleep issues.
Additionally, it has been found to help in cases of post-viral fatigue, as is often the case with adaptogenic herbs, and so may be beneficial in cases where fibromyalgia onset seemed to follow a viral infection.
Caution regarding sustainability issues: rhodiola is endangered in the wild, so only use it when it is either cultivated, or from certified sustainable sources.
Ashwagandha works as a nervous system tonic, with adaptogenic properties, helping to improve the body’s resilience to stress, and to readdress balance in the stress response system. Ashwagandha is also particularly helpful in cases of sleep difficulties such as can occur with fibromyalgia. It can help to restore better quality sleep, laying a tonifying foundation for the nervous system which allows the body to sustain good quality, deep, and restorative sleep.
Despite being helpful for relaxing and restoring the nervous system and sleep, for some people who are very depleted, ashwagandha can feel either too stimulating, or too sedating creating a feeling of sleepiness. This can be managed by adjusting when the herb is consumed, such as either in the daytime if it feels stimulating, as the beneficial impact on sleep will not be lost even when taken during the daytime, or taken only at night-time if it creates a heavy or sedating feeling.
Ginseng is another helpful herb to be explored in cases of fibromyalgia, which has adaptogenic and tonic properties, being particularly beneficial in cases of post-viral syndromes, for example when fibromyalgia onset may follow a viral infection. Ginseng can also help to ease fatigue, and improve mental performance and concentration, making it particularly helpful when these are present with fibromyalgia.
Reishi mushroom is an immune modulating tonic with adaptogenic properties. It helps to modulate the body’s stress response system, and is indicated by herbalists in fibromyalgia, particularly when its onset seems to follow a virus.
Nervous system support
St John’s wort is a very nourishing nervous system tonic with a tradition of being given for sleep issues. It helps to restore the quality and function of the nervous system tissues, and this restorative effect allows better quality sleep to be possible. It is particularly beneficial when sleep issues are associated with emotional stress, anxiety, or depression, so can be considered as a helpful herb in cases of fibromyalgia accompanied by any of these presentations.
Pain Relieving Herbs
Celery seed is a helpful herb in cases of pain from musculoskeletal conditions, and can relieve muscular tension, making it a potentially helpful herb in the management of the pain symptoms associated with fibromyalgia.
Bupleurum has been given as a selective analgesic remedy for centuries in Iranian folk medicine. This may be due to the saponin content which exhibits pain relieving properties in other types of pain.
A recent study suggested that bupleurum root essential oil demonstrated antinociceptive effects (10). Although this study seems to demonstrate that bupleurum has antinociceptive pain-relieving effects, it was carried out on mice and so is not applicable to human subjects. However, this may shed light on the mechanisms of action for its long traditional application in relieving pain and demonstrates that it may be helpful in conditions such as fibromyalgia, where pain due to antinociceptive system imbalances is a big factor.
Holistic solutions
What lifestyle changes, therapies and practises can be helpful here? Nutritional advice is also welcome here.
Dietary recommendations:
- Wholefood diet (poultry, fish, vegetables, fruits). Minimize foods which contribute to chronic pain, such as arachidonic acid (7).
- Reduce refined carbohydrates, which contribute to insulin imbalances (7).
Exercise to tolerance will help to keep body mobile and reduce muscular tension.
Acupuncture: A study examining the effects of acupuncture treatment on fibromyalgia symptoms, serotonin and substance P levels found that serum serotonin levels were significantly increased after treatment, and substance P levels decreased. Significant improvements were found in almost all clinical outcomes after treatment (which included number of tender points, and fibromyalgia impact questionnaire), and usually continued three months after treatment. This suggests that acupuncture may be a helpful treatment in the management of fibromyalgia symptoms (11).
Managing stress will be helpful in managing fibromyalgia due to the potential impact of the stress response system on this condition.
References
- Sarzi-Puttini, P., Giorgi, V., Marotto, D. et al. Fibromyalgia: an update on clinical characteristics, aetiopathogenesis and treatment. Nat Rev Rheumatol. 2020:16;645–660. https://doi.org/10.1038/s41584-020-00506-w.
- Häuser W, Ablin J, Fitzcharles MA, Littlejohn G, Luciano JV, Usui C, & Walitt B. Fibromyalgia. Nature Reviews Disease Primers. 2015:1;15022.
- Fibromyalgia Facts. Fibromyalgia Action UK. https://www.fmauk.org/information-packs-mainmenu-58/useful-information-1/548-fibromyalgia-facts?start=1#:~:text=Seen%20in%20about%202%25%20of,20%2D60%20years%20of%20age. Accessed April 13, 2024.
- Wilson, N., Beasley, M.J., Pope, C. et al. UK healthcare services for people with fibromyalgia: results from two web-based national surveys (the PACFiND study). BMC Health Serv Res 22, 989 (2022). https://doi.org/10.1186/s12913-022-08324-4.
- Griep EN, Boersma JW, Lentjes EG et al. Function of the hypothalamicpituitary-adrenal axis in patients with fibromyalgia and low back pain. J. Rheumatol. 1998:25(7);1374-1381.
- Neeck G. Pathogenic mechanisms of fibromyalgia. Ageing Res Rev. 2002:1(2);243-255.
- Pizzorno J, Murray M, Joiner-Bey H, The Clinician’s Handbook of Natural Medicine. 2nd ed. St Loius, Missouri: Churchill Livingstone Elsevier; 2008.
- Fibromyalgia. NHS. https://www.nhs.uk/conditions/fibromyalgia/. Accessed May 1, 2024.
- Frawley D, Lad V. The Yoga of Herbs. 2nd ed. Twin Lakes: Lotus Light Publications; 2008.
- Ahmadimoghaddam D, Zarei M, Mohammadi S, Izadidastenaei Z, Salehi I. Bupleurum falcatum L. alleviates nociceptive and neuropathic pain: Potential mechanisms of action. Journal of Ethnopharmacology. 2021:273;113990. https://doi.org/10.1016/j.jep.2021.113990.
- Karatay S, Caglar Okur S, Uzkeser H, Yildirim K, Akcay F. Effects of Acupuncture Treatment on Fibromyalgia Symptoms, Serotonin, and Substance P Levels: A Randomized Sham and Placebo-Controlled Clinical Trial. Pain Medicine. 2018:19;3.615–628. https://doi.org/10.1093/pm/pnx263.
