Understanding and Managing Fibromyalgia: Brain, Spinal Cord, and Peripheral Factors

Photo of author
Written By Dr. Marcus Yu Bin Pai

MD, PhD. Physical Medicine & Rehabilitation Physician from São Paulo - Brazil. Pain Fellowship in University of São Paulo.

Fibromyalgia is a complex and widely misunderstood condition characterized by chronic widespread pain, fatigue, and other symptoms. Recent research has helped us understand some of the key mechanisms underlying fibromyalgia, including brain networks, spinal cord dysfunction, and peripheral nerve abnormalities.

Fibromyalgia is not solely a physical condition, but rather a complex interplay between the body and the brain. The disorder is believed to involve alterations in the processing of pain signals within the central nervous system, resulting in heightened sensitivity to pain.

This heightened sensitivity, known as central sensitization, leads to the characteristic widespread pain experienced by fibromyalgia patients.

In this article, we will explore these findings and discuss how they can inform the management of fibromyalgia.

Epidemiology of Fibromyalgia

Fibromyalgia affects 3-5% of the general population and is more common in women than in men, with a female-to-male ratio of approximately 5:1. It can occur at any age but is most prevalent during the mid-years, particularly in the 40s and 50s.

Individuals with chronic illnesses have a ten times higher rate of fibromyalgia than the general population.


Fibromyalgia often coexists with other conditions, such as chronic fatigue syndrome, irritable bowel syndrome, irritable bladder syndrome, regional pain syndromes (e.g., temporomandibular joint syndrome), restless legs’ syndrome, multiple chemical sensitivity, dizziness, and nausea.

There is a 30-40% overlap between these conditions and fibromyalgia, suggesting shared underlying mechanisms.

Misconceptions and Diagnostic Challenges

There is a common misconception that fibromyalgia is a psychosomatic condition or “all in one’s head.” However, recent research has shown that fibromyalgia is indeed a neurological disorder, and the pain experienced by patients is very real. Diagnosing fibromyalgia can be challenging, as there is no definitive diagnostic test, and symptoms often overlap with other conditions.

Brain Networks and Pain Pathways in Fibromyalgia

Studies have identified changes in the brain networks of fibromyalgia patients, with a focus on pain pathways. Dysfunctional pathways linking serotonin and noradrenaline have been observed, which may contribute to the chronic pain experienced by fibromyalgia patients. This dysfunction may explain why opioids, which typically target opioid pathways, are often ineffective in treating fibromyalgia pain.

The Role of Centralized Pain

Centralized pain is a key component of fibromyalgia, and understanding its implications can greatly influence treatment strategies. For example, patients with fibromyalgia may experience pain in their knee, despite having a normal x-ray. This highlights the importance of considering centralized pain when treating fibromyalgia, as traditional treatments targeting peripheral pain may not be effective.

Central Sensitization and Spinal Cord Dysfunction

Central sensitization, a phenomenon in which pain neurons become more active and sensitive, has been observed in the dorsal horn centers of the spinal cord in fibromyalgia patients. This increased sensitivity may be due to the release of certain chemicals, such as substance P and glutamate, which make the neurons more responsive to input. As a result, signals from mechanoreceptors in the muscles and joints, which typically transmit information about movement rather than pain, may now be interpreted as painful stimuli.

Peripheral Nerve Abnormalities

Recent research has also identified abnormalities in the small fibers of fibromyalgia patients’ peripheral nerves. These fibers may be reduced in number and exhibit abnormal anatomy, potentially due to the release of neuropeptides from activated C fibers. This damage to regional nerves may contribute to fibromyalgia symptoms, but further research is needed to understand the exact relationship.

Pain Origins and Amplification in Fibromyalgia

The exact origin of pain in fibromyalgia is still not fully understood, but several factors likely contribute. The central sensitization and amplification of pain signals in the spinal cord appear to be key mechanisms, while potential pain generators in the body, such as arthritis, tight muscles, poor posture, and neuroinflammation, may also play a role.

Identifying and Treating Different Types of Pain

Fibromyalgia patients may experience various types of pain, including nociceptive, neuropathic, and centralized pain. Each type of pain requires a different treatment strategy, making it essential for healthcare providers to accurately identify and address the specific pain sources experienced by each patient.

Targeting Neurotransmitters

Several neurotransmitters play a role in the pain experience of fibromyalgia patients. Some neurotransmitters facilitate pain transmission, while others inhibit it. Medications targeting these neurotransmitters can help alleviate fibromyalgia symptoms.

For example, low-dose naltrexone, an emerging therapy, works by blocking endogenous opioids to increase the availability of opioid receptors, thus improving pain relief.

Management Strategies for Fibromyalgia

Effective management of fibromyalgia requires a comprehensive approach that includes evaluation, identification of key symptom domains, and consideration of comorbid conditions. Key components of a fibromyalgia management plan may include patient education, low-impact aerobic exercise, psychological strategies, and medications that target specific pathways in the fibromyalgia cascade. Some commonly used medications include low-dose tricyclic antidepressants, gabapentinoids, and serotonin-norepinephrine reuptake inhibitors (SNRIs).

Non-Pharmacologic Therapies

Strong evidence supports the use of non-pharmacologic therapies for fibromyalgia management, such as education, physical therapy, exercise, and cognitive-behavioral therapy. However, access to these treatments may be limited for some patients due to financial constraints or geographical barriers.


Fibromyalgia is a complex condition that involves multiple factors, including brain networks, spinal cord dysfunction, and peripheral nerve abnormalities. As our understanding of these mechanisms grows, so too will our ability to effectively manage and treat fibromyalgia.

A comprehensive, multifaceted approach to treatment is essential to address the diverse symptoms and challenges faced by fibromyalgia patients.

Website | + posts

MD, PhD. Physical Medicine & Rehabilitation Physician from São Paulo - Brazil. Pain Fellowship in University of São Paulo.

Leave a Comment