A board-certified internist and expert in pain and sleep explains how to easily diagnose and treat fibromyalgia, including how and why it’s so important to optimize sleep in these patients.
Fibromyalgia affects approximately 2% of the population, or 4 million Americans. About another 2% have a milder form where they do not quite meet the diagnostic criteria but still manifest severe symptoms. Unfortunately, the majority of people with fibromyalgia have not yet received the correct diagnosis. Identifying fibromyalgia is critical in treating sleep disorders, as this condition results in severely disordered sleep and can be very effectively treated (once the diagnosis is made).
What Is Fibromyalgia?
Put simply, fibromyalgia reflects a severe energy crisis in the human body, from literally dozens of causes. The energy crisis essentially “trips a circuit breaker” resulting in secondary hypothalamic dysfunction, whereas effective hypothalamic function is critical for regulating sleep. The hypothalamus (via the pituitary) also regulates the hormonal system, autonomic function, and temperature.
Low energy in the muscles causes them to get stuck in the shortened position, triggering chronic pain. This is because it takes more energy for a muscle to relax than to contract. This is why muscles get tight after a workout, instead of loose and limp. Chronic muscle pain then triggers secondary central sensitization, nerve pain, and a host of other pains. Pain can then worsen the already disrupted sleep.
What’s more, the association between sleep and pain is bidirectional. Since sleep is when growth hormone is released and tissue repair occurs, good sleep is important to alleviate pain.
Diagnosing fibromyalgia is straightforward. A fibromyalgia process is likely when the person has widespread pain and the paradox of difficulty sleeping despite exhaustion. This is the case even if there is another primary process such as lupus, multiple sclerosis, or rheumatoid arthritis that triggers fibromyalgia secondarily. Secondary fibromyalgia needs to be treated separately from the primary autoimmune disease, so it is critical to maintain a high level of suspicion when a patient with an autoimmune illness presents with disordered sleep. Research shows that about 25% to 35% of people with these autoimmune illnesses will have a secondary fibromyalgia.
Diagnosing fibromyalgia is easy using the American College of Rheumatology Amended 2010 diagnostic criteria. My website provides a free and simple online quiz that screens patients using the diagnostic criteria. If you email me at FatigueDoc[at]gmail.com, I will also send you a simple form containing the diagnostic criteria, which you can have people fill out in your office. Using either of these tools, you can diagnose fibromyalgia accurately in under one minute.
Fibromyalgia can be effectively treated (p<.0001 vs placebo with an average 90% improvement in quality of life in our published study) by using the S.H.I.N.E. Protocol. S.H.I.N.E. addresses and optimizes:
Sleep. Sleep is the focus of this article, so continue reading for more details.
Hormonal function and hypotension. Thyroid, adrenal, and ovarian/testicular function need to be optimized, in some cases this means treatment despite “normal” lab tests. Optimizing thyroid hormone triiodothyronine (T3) is especially important.
Infections. Dozens of infections have been implicated in fibromyalgia, with immune dysfunction being routine.
Nutritional support. For example, research shows a nutrient called D-ribose increases energy an average of 61% in patients with fibromyalgia.
Exercise as able. Maintaining conditioning is important in most chronic illnesses (cancer, for example) and fibromyalgia is no exception.
To simplify treatment, the Energy Analysis Program can be done at www.vitality101.com. This free 10-minute quiz will determine the underlying causes of low energy and tailor a S.H.I.N.E. based protocol to optimize energy.
Optimizing Sleep in Fibromyalgia
It is important to screen for sleep apnea, restless leg syndrome, and upper airway resistance syndrome (UARS), all of which are often seen in association with fibromyalgia. Our clinical experience shows treating candida overgrowth is critical for UARS. Suspect candida overgrowth when nasal congestion and irritable bowel syndrome are present. I typically treat with the antifungal Diflucan (fluconazole) 200 mg a day for 6 weeks plus the antifungal nystatin 500,000 units twice a day for 4 months. Compounded sinusitis sprays are available (for example, ITC Compounding Pharmacy’s Sinusitis Nose Spray) that markedly increase the effectiveness of these oral treatments.
Because of the severity of the disordered sleep in fibromyalgia, no single treatment will be enough. For people to be able to get the 8 hours sleep a night needed for the pain and fatigue to heal, they will require a mix of many of the treatments detailed below. I find people do best with a low dose of several treatments combined, instead of a high dose of one; the latter leaves them hung over until well into the next afternoon and with other significant side effects.
Because sleep medications worsen sleep apnea, sleep specialists are appropriately wary about using them in those with sleep apnea. But in fibromyalgia, the person’s need to optimize sleep is so critical that I will prescribe zolpidem to initiate sleep and low doses of medications such as trazadone, gabapentin, and cyclobenzaprine to help maintain sleep. Once these are adjusted so the patient gets 7 to 8 hours of sleep a night, I will recheck the sleep study and adjust the CPAP pressures as needed to compensate.
Although the disordered sleep in fibromyalgia is not caused by poor sleep hygiene, several hygiene measures can help improve sleep in these patients to some extent:
- Because of the HPA (hypothalamic pituitary adrenal) axis dysfunction, cortisol levels are often too high at bedtime, preventing the person from falling asleep. Then they often plummet during sleep, resulting in dropping blood sugar, which then wakes the person and leaves them wide-awake (often with night sweats). So giving a 1 oz protein snack at bedtime, such as a hard-boiled egg, meat, or fish, can be helpful for maintaining blood sugars.
- Because of the autonomic dysfunction, nighttime acid reflux often wakes the person with night sweats. Using a sleep wedge pillow to raise the body from the waist (for example, The Sleep Improving Wedge from Hammacher Schlemmer) and taking ½ teaspoon of baking soda in 4 oz of water at bedtime (to neutralize stomach acid) can be helpful (have them take a few sips of water after to wash it down). Do not use chronic proton-pump inhibitors (PPIs), as using PPIs for over 6 weeks has been shown to be addictive (causing rebound acid hypersecretion when stopped) and toxic, markedly increasing the risk of Alzheimer’s disease, osteoporosis, and death. If they are needed, use Tagamet or Zantac, which are safer.
Natural Sleep Aids
Several herbal mixes are especially helpful. These can be used in combination and include:
- Enzymatic Therapy’s Revitalizing Sleep Formula, which is a mix of valerian, passionflower, 5 HTP, theanine, lemon balm, and hops.
- EuroPharma’s Terrific Zzzz, which is a mix of essential oils including mandarin zest oil, lemon balm, ravintsara, and lavender.
- If the person has trouble falling asleep (s/he may say the mind is racing), this often reflects elevated cortisol at bedtime. Integrative Therapeutics’ Cortisol Manager, which is formulated with ashwagandha, L-theanine, phosphatidylserine, magnolia, and epimedium, taken an hour before bedtime can help.
- Although minimally effective on its own, melatonin can be helpful with other therapies. I recommend Nature’s Bounty Dual Spectrum Bi-Layer Melatonin 5 mg, which provides both immediate and sustained release.
- To decrease nighttime pain (and pain in general), the Terry Naturally Curamin Supplement is an outstanding herbal mix. It takes 6 weeks to see the full effect, but initial effects are seen after first dose. Also consider recommending Epsom salts baths (2 cups of Epsom salts in a tub of hot water 30 minutes before bedtime) to help pain-compromised sleep.
- In women over 45 or who have had a hysterectomy (even if the ovaries were left), consider a mix of estrogen patches and Prometrium (progesterone). Progesterone is critical for sleep, even if the woman’s uterus has been removed.
I do sell many of these supplements on my site www.endfatigue.com, but I do not accept money from any pharmaceutical or supplement companies; the supplements are also available at most health food stores.
Prescription Medications for Sleep
Patients with fibromyalgia generally require medication to both initiate and maintain sleep.
To initiate sleep, I find Ambien (zolpidem) to be most effective. I sometimes recommend part of the dose be taken sublingually during middle of the night awakenings.
To maintain sleep, a combination of the prescription pharmaceuticals listed below can be helpful. I have patients try each to see what is tolerated and works best and then combine them as needed:
- Desyrel (trazodone). 25 to 50 mg bedtime
- Neurontin (gabapentin). 100 to 400 mg at bedtime
- Elavil (amitriptyline). 10 to 25 mg at bedtime (this combined with gabapentin is especially helpful when pelvic pain is present)
- Zanaflex (tizanidine). 2 to 4 mg at bedtime (do not combine with the antifungual Diflucan mentioned earlier)
There are literally dozens of other treatments that can be helpful for sleep in fibromyalgia, but the approach described here will dramatically help the overall process in the large majority of cases. You will find your patients are appreciative at their overall clinical improvement. When you optimize sleep using this protocol, patients will experience improved energy and cognitive function and markedly decreased pain.
Jacob Teitelbaum, MD, is a board-certified internist and integrative medical expert. He is the author of the best-selling From Fatigued to Fantastic!; Pain Free 1-2-3; The Complete Guide to Beating Sugar Addiction; Real Cause, Real Cure; The Fatigue and Fibromyalgia Solution; and the free smart phone app Cures A-Z. He is the lead author of 4 studies on effective treatment for fibromyalgia and chronic fatigue syndrome and a study on treatment of autism using NAET (Nambudripad’s Allergy Elimination Techniques).