Pain in Fibromyalgia — Identification and Treatment of the Dominant Pain Syndrome

Author: Dr. Zeljko Kojadinovic, MD, PhD – Neurosurgeon and Pain Management Specialist

Last medically reviewed: June 10, 2026

Many people diagnosed with fibromyalgia feel pain “everywhere,” yet in clinical reality one or a few regions usually dominate — the neck, shoulders, low back, or pelvis.
Real improvement often begins when the physician identifies what exactly hurts within a local pain syndrome — and why: whether it is a muscle in spasm, an inflamed tendon or a compressed nerve.
Effective management then requires two parallel levels of care: treatment of fibromyalgia as a systemic pain condition, and treatment of the specific causes of the dominant pain syndromes that maintain or amplify it.

What Is Fibromyalgia?

Fibromyalgia is a systemic pain-sensitivity disorder, but many patients also have dominant local pain generators that must be diagnosed and treated separately.

Definition

Fibromyalgia is a chronic pain syndrome characterized by widespread musculoskeletal pain, fatigue, and non-restorative sleep.
Fibromyalgia involves two closely interacting mechanisms.
The first is a disturbance of pain neuromodulation within the central nervous system — including the brain and spinal cord — where pain-transmitting neurons become overly sensitive (central sensitization) and the normal descending inhibitory pathways that regulate pain perception become less effective. This leads to an exaggerated pain response even to mild stimuli.
The second mechanism is a tendency of the body to develop and sustain local musculoskeletal pain sources such as low-grade inflammation, muscle spasm, or nerve irritation. This occurs because in fibromyalgia there is a predisposition of the tissues to metabolic and microcirculatory disturbances, and mild activation of inflammatory pathways in muscles, fascia, and small nerve fibers. These changes make the tissues more reactive to everyday mechanical or metabolic stress and more likely to maintain chronic pain.

Central sensitization often coexists with ongoing pain input from local sources in muscles, fascia, or small nerves, which are responsible for the predominant pain in certain body regions. Both mechanisms contribute to the pain and other symptoms of fibromyalgia, yet treatment is frequently focused only on the central disturbance of neuromodulation, while local pain syndromes remain underrecognized and undertreated. In practice, effective management requires addressing both — restoring normal pain modulation in the nervous system and identifying treatable local pain generators.

Who Is Affected

• Most common in women between 30 and 60 years old.
• Prevalence is estimated at 2–4% of the general population.
• Fibromyalgia often overlaps with other chronic pain syndromes such as irritable bowel syndrome, temporomandibular joint disorder, chronic pelvic pain, and tension-type headache.
• Symptoms can start or worsen after infection, emotional stress, trauma, or surgery.

Main Symptoms

• Diffuse aching or stiffness in multiple body regions lasting over 3 months.
• Fatigue, feeling unrefreshed after sleep, and morning stiffness.
• Cognitive issues (“fibro-fog”) — problems with focus and memory.
• Headache, tingling, jaw or chest wall pain, and sensitivity to pressure or temperature.
• Depression and anxiety are common in fibromyalgia, often developing as a reaction to chronic pain, poor sleep, and reduced daily functioning. However, the two conditions are distinct diagnoses and should not be reduced to one. A person with depression may experience pain or tenderness, and if fibromyalgia criteria are met, both diagnoses are made. Likewise, patients with fibromyalgia often experience low mood or anxiety, and when full diagnostic criteria for depression are present, that diagnosis is added in addition to fibromyalgia.
• Importantly, many patients have one region that hurts far more than others — which often represents a dominant pain generator such as low back pain, neck pain, interstitial cystitis/bladder pain syndrome, intercostal neuralgia, occipital headache, sciatica, and others.

Diagnosis

Fibromyalgia is diagnosed clinically — there is no single laboratory test or imaging study that confirms it. Doctors use the Widespread Pain Index (WPI) and the Symptom Severity (SS) Scale to evaluate how many body regions are painful and how intense the accompanying symptoms are. The WPI covers up to 19 possible painful areas that patients report themselves, and physicians usually ask about each of these regions to ensure that none are missed. This modern approach replaced the older method that required tenderness on 11 of 18 specific pressure points during examination. The SS Scale rates fatigue, sleep problems, and cognitive symptoms from 0 to 3 each.

A diagnosis of fibromyalgia is usually made when pain is present in at least four of five body regions (left upper, right upper, left lower, right lower, and axial), symptoms have lasted for three months or longer, and no other disorder better explains the pain pattern. Laboratory tests and imaging are performed mainly to exclude other causes such as thyroid disease, autoimmune inflammation, neuropathies, or vitamin deficiencies.

Diagram showing Widespread Pain Index (WPI) body map and Symptom Severity (SS) Scale used in the diagnosis of fibromyalgia.

General Treatment

Effective pain management depends not only on reducing peripheral irritation or central sensitization, but also on preserving the body’s natural pain-control systems — the descending neuromodulation pathways.
Just as antibiotics work best when the immune system is at least partly preserved, pain treatments are most effective when the brain’s natural inhibitory mechanisms are still functional and can be strengthened through rehabilitation, movement, and proper sleep.

The most effective strategy is multimodal therapy combining education, lifestyle modification, and specific symptom management:

• Patient education and reassurance — the pain is real, not psychological.
• Regular, low-impact exercise such as walking, swimming, or stretching.
• Sleep regulation and stress management — cognitive-behavioral therapy, relaxation techniques, mindfulness.
• Medications (when indicated): Medications that can help reduce pain and improve sleep include duloxetine (Cymbalta), pregabalin (Lyrica), or low-dose amitriptyline (Elavil). These are prescribed individually based on symptom profile, coexisting conditions, and tolerance.
• Physical therapy: gentle strengthening, stretching, and postural correction.

These measures reduce central sensitization, but in many patients they do not fully resolve the pain because the local pain sources remain untreated.

When dominant local pain syndromes are recognized and treated alongside general measures, most patients achieve better pain control and quality of life.

Local Pain Sources in Patients with Fibromyalgia

Although fibromyalgia is defined as “widespread pain,” it rarely feels equal in every region.
Most patients can point to one or two areas that constantly hurt more than the rest — for example, the neck, shoulders, low back, pelvic floor, or chest wall.
These regions often behave like classic localized pain syndromes involving the same mechanisms seen in other chronic pain conditions:

• Muscle spasm or myofascial trigger points leading to sustained local tenderness and referred pain, especially when they compress nearby sensory nerves.
• Low-grade inflammation in muscles, tendons, joints, or fascia that irritates sensory nerve endings or adjacent nerve branches.
• Nerve irritation or compression causing pain and, over time, structural or functional changes in the nerve that lead to neuropathic pain and heightened sensitivity.
• Fibrotic or degenerative changes in connective tissue — such as fascial thickening, peri-tendinous fibrosis, or tiny adhesions between tissue layers — can limit normal sliding and flexibility of muscles and fascia, creating constant mechanical tension that maintains local inflammation or compresses nearby nerves.
• Joint or ligament micro-instability — often resulting from loose connective tissue, repetitive strain, or poor posture — can cause abnormal traction on joint nerves, leading to reflex muscle spasm and persistent pain in surrounding structures.
• Microcirculatory and metabolic disturbances reducing oxygen supply and promoting muscle fatigue and stiffness, often amplifying the above mechanisms.

Although central sensitization is a key mechanism in fibromyalgia, peripheral nociceptive and somatic factors often contribute as well, creating a complex interaction between local and central pain processes.

How the Dominant Pain Source Is Identified in Fibromyalgia

In fibromyalgia, local pain syndrome almost never arises from a single source. Instead, several mechanisms usually overlap — including muscle tension, connective-tissue irritation, nerve hypersensitivity, and central sensitization.
The goal of evaluation is not to “find one cause,” but to determine how much each component contributes in every painful region.

1. Detailed pain history
The process starts with precise mapping of all pain areas — their onset, duration, daily fluctuation, and aggravating or relieving factors. Patients are asked about posture, repetitive activity, sleep quality, and stress triggers that may influence pain intensity.

2. Focused physical examination
Palpation identifies tense or shortened muscles, local trigger points, or zones of neuropathic sensitivity. Passive and active motion tests help reveal whether pain originates mainly from muscles, joints, or nerve structures.

3. Targeted diagnostic tests
If localized pathology is suspected, ultrasound or MRI may confirm inflammation, tendon overload, or nerve compression. Laboratory testing is used selectively to exclude systemic or rheumatologic diseases that may mimic fibromyalgia.

4. Diagnostic (test) injections when indicated
Small test injections with lidocaine — usually guided by ultrasound — can help confirm the exact pain generator, such as a peripheral nerve branch or a deep myofascial trigger zone.

5. Mechanism-based interpretation
Each painful region is analyzed to estimate the relative contribution of myofascial tension, inflammatory or overuse processes, and neuropathic or compressive mechanisms — because in most patients, several of these components coexist.
Recognizing this pattern allows therapy to target both local and central mechanisms, improving pain control and functional recovery.

Treatment prioritization: begin with the most limiting or constant pain area; combining local and general therapy gives best results.

Treatment Approach for Dominant Pain Source in Fibromyalgia

General fibromyalgia care — including sleep optimization, stress reduction, and aerobic conditioning — remains essential.
However, the missing step for many patients is the targeted treatment of the dominant local pain generators.

If Muscle Spasm or Myofascial Pain Dominates

• Daily stretching and breathing-based relaxation.
• Myofascial release, gentle manual therapy, or dry needling.
• Local heat therapy or short sessions of low-intensity exercise.
• Short-term muscle relaxants are sometimes prescribed for fibromyalgia at night if severe sleep-related spasm is present.

If Local Inflammation or Overuse Is Present

• Postural correction and ergonomic adjustments.
• Controlled movement: slow, eccentric muscle work and core stabilization.
• NSAIDs, topical anti-inflammatory gels, or brief courses of non-opioid analgesics.
• Ultrasound-guided injections when conservative measures fail.

If Neural Irritation or Compression Exists

• Nerve-gliding and decompression-focused stretching.
• Adjust posture and workspace to minimize neural tension.
• Consider neuropathic-pain medications if symptoms persist.
• Diagnostic or therapeutic nerve block may be used to confirm the mechanism.

The care involves both general pain-management principles for fibromyalgia and local treatment methods for specific pain syndromes such as low back pain, neck pain, interstitial cystitis / bladder pain syndrome, intercostal neuralgia, occipital headache, sciatica, and others.

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Online pain consultation for regional pain in detail

Schematic explanation of the video consultation for regional pain

Answers to questions about the process and success of video consultations for regional pain

There are several common reasons for poor therapeutic outcomes in the treatment of chronic pain, which are often seen in patients with regional pain.

Artificial intelligence can also support the process by analyzing complex pain syndromes in fibromyalgia, but clinical expertise remains essential.

Why This Approach Works

Treating the dominant local pain source reduces the constant nociceptive input that fuels central sensitization.
As peripheral pain subsides, overall fibromyalgia pain often decreases as well — patients sleep better, move more easily, and need fewer medications.
In clinical studies (Affaitati 2011, Gerwin 2013, Staud 2011), this combined local + central approach consistently improves global pain ratings and function.

Why Pain Often Persists Despite Fibromyalgia Treatment

Pain often persists despite fibromyalgia treatment because treatment reduces central sensitization but does not always identify and treat the dominant local pain generator, such as low back pain, neck pain, pelvic pain, headache, chest wall pain, or nerve-related pain.

In many patients, pain does not persist because fibromyalgia treatment is incorrect, but because it remains incomplete — focused mainly on central sensitization while local pain sources are not fully identified or treated.

First, the dominant local pain generator is not clearly defined. Although fibromyalgia is characterized by widespread pain, most patients have one or a few regions that hurt significantly more than others. These areas often represent specific pain syndromes — such as muscle spasm, tendon irritation, or nerve involvement — which require targeted treatment but are frequently attributed only to “fibromyalgia.”

Second, the underlying pathological process within these local pain areas is not distinguished. Muscle tension, low-grade inflammation, mechanical overload, and nerve sensitization each require different therapeutic approaches, yet treatment is often applied without identifying which mechanism predominates in a given region.

Third, contributing factors that maintain local and central pain are frequently underestimated. These include posture, repetitive strain, poor sleep, autonomic imbalance, and metabolic or nutritional influences. Even when general fibromyalgia therapy is appropriate, these factors can continue to amplify pain signals and limit recovery.

Because of this, treatment may appear appropriate and partially helpful, yet pain remains, fluctuates, or returns — especially in the same dominant regions. More complete improvement is usually achieved only when both central sensitization and local pain generators are addressed together in a coordinated, mechanism-based approach.

Prognosis and Long-Term Management

Fibromyalgia itself does not cause tissue damage or paralysis.
Pain intensity fluctuates, but the long-term outlook is favorable when patients adopt self-management strategies and local sources of pain are treated as they arise.
Periodic reassessment prevents chronic flare-ups from becoming entrenched.
The goal is not “pain-free forever,” but a stable, active life with manageable symptoms.

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