There is no single most effective modality for the treatment of fibromyalgia syndrome, and no objective comparison of the results from the different studies is available. Low-dose tricyclic antidepressants (TCAs) improve sleep quality and global well-being and have a moderate beneficial effect on tenderness and stiffness (strength of recommendation [SOR]: A, based on a systematic review of randomized controlled trials [RCTs]). Selective serotonin reuptake inhibitors (SSRIs) may moderately improve fibromyalgia-related symptoms (SOR: B, based on a few RCTs). The serotonin and norepinephrine reuptake inhibitors (SNRIs) duloxetine (Cymbalta) and milnacipran (Ixel, not currently available in the US) improve pain and other symptoms (SOR: B, based on single RCTs). Tramadol (Ultram) improves pain and other outcomes (SOR: A, based on a few RCTs). Cyclobenzaprine (Flexeril) improves both pain and sleep quality (SOR: A, based on a systematic review of RCTs). Aerobic exercise improves overall functional capacity and sense of well-being for patients with fibromyalgia (SOR: A, based on a systematic review of RCT). Cognitive behavioral therapy improves patients' self-reported symptoms (SOR: A, based on RCTs)
