Which medications are available to improve sleep in patients with fibromyalgia?

Updated: Apr 23, 2020
  • Author: Chad S Boomershine, MD, PhD, CPI, CPT; Chief Editor: Herbert S Diamond, MD  more...
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If proper education and instruction on sleep hygiene and dietary changes fail to provide adequate improvement in the patient’s sleep, consider using appropriate medications. Sleep problems may be treated with the following:

  • Antidepressants (eg, trazodone, SSRIs, SNRIs, tricyclic antidepressants)
  • Anticonvulsants (eg, clonazepam, gabapentin, tiagabine, pregabalin)
  • Nonbenzodiazepine hypnotics (eg, zolpidem, zaleplon, eszopiclone)
  • Muscle relaxants (eg, cyclobenzaprine, tizanidine)
  • Dopamine agonists (eg, pramipexole, ropinirole)

Sleep-maintenance disorders are more difficult to manage than are sleep-onset problems. In general, antidepressants are most commonly used because of their effect on serotonin. Tricyclic antidepressants have the strongest evidence for efficacy. The criterion standard is amitriptyline, but many patients cannot tolerate this drug.

Trazodone is inexpensive, well-tolerated, and effective. It should be taken at 8 pm. The starting dose is 25 mg, If necessary, the dose can be slowly titrated upward. If the patient is not staying asleep, adding an SSRI may be helpful.

If the patient has concomitant restless legs syndrome or mitral valve prolapse, clonazepam may be the drug of choice. The starting dose is 0.125 or 0.25 mg taken at 8 pm. Titrate the dose to the lowest effective dose.

Tiagabine increases sleep efficiency with a marked increase in slow-wave sleep in healthy elderly patients. Tiagabine titrated from 2 mg to 12 mg may improve sleep maintenance in some patients.

Gabapentin may also aid in sleep maintenance. [145] Evidence suggests that pregabalin, which is approved for use in fibromyalgia by the US Food and Drug Administration (FDA), is effective for improving sleep. [157]

The dopamine agonist pramipexole (Mirapex) is FDA approved for the treatment of moderate to severe restless legs syndrome. This medication may aid in sleep maintenance in patients with fibromyalgia and restless legs syndrome. It is also under investigation as a treatment for fibromyalgia pain. [158, 155]

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