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Strategies for Pain

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By Bruce Campbell

(Note: From the series Treating ME/CFS and Fibromyalgia.)

Pain is usually the central symptom in fibromyalgia and is often a problem for people with Chronic Fatigue Syndrome (ME/CFS) as well.

For people with FM, pain is generally felt all over the body, though it can start in one region and spread or move from one area to another. It may be accompanied by neurological problems such as intermittent tingling and burning or numbness in the hands, arms, feet, legs or face.

For people with ME/CFS, pain may be experienced in the joints or, more commonly, as an overall body pain sometimes described as feeling like being run over by a truck.

Because pain in either condition can have a variety of causes, it is usually managed with a variety of strategies such as the following:

  • Pacing
  • Exercise
  • Posture & movement
  • Relaxation
  • Addressing worry, frustration & depression
  • Treating fatigue and poor sleep
  • Heat, cold & massage
  • Problem solving
  • Distraction
  • Healthy self-talk
  • Medications

A frequent cause of pain is overdoing or having an activity level that is beyond a person's limits. Pacing offers a way to bring stability and control by keeping activity level within the limits imposed by illness.

Pacing can involve a variety of strategies, including: reducing overall activity level, delegating, alternating activity and rest, having short activity periods, switching between high and low intensity tasks, using the best hours of day for the most demanding activities, staying within limits for mental and social activity, and keeping records to see links between activity and symptoms.

Pacing is the heart of lifestyle adjustment to ME/CFS and FM, and helps control all of the four main symptoms. For ideas on how to incorporate pacing into your life, see our Pacing Tutorial and articles in the Pacing archive.

Exercise is one of the most-commonly prescribed treatments for FM and can be helpful for ME/CFS as well. An exercise program done regularly can help reduce stiffness, counteract deconditioning and improve outlook.

Though frequently a cause of relapses, exercise need not trigger a flare if done properly. A program of gentle stretching can be helpful for both FM and ME/CFS. For ideas on how to exercise safely, see the article Exercise.

Posture & Movement
People with fibromyalgia can help reduce their pain by experimenting with how they hold their body and how they move. Many find that staying in one position for an extended period of time, sometimes as little as 20 to 30 minutes, increases stiffness and intensifies pain.

Moving periodically can help, as can limiting the length of time spent doing repetitive motions like chopping vegetables. Some people are helped by Tai Chi.

Being attentive to posture can help as well. Since people with FM tend to slouch, which puts tension on muscles in the neck and shoulders, Dr. Lapp teaches his patients to sit up straight, holding the shoulders back and tucking in the chin.

The experience of pain is intensified by stress and by emotions like worry, frustration and depression. Emotions create muscle tension, which is directly painful. Emotions also contribute to the experience of pain indirectly by increasing stress and a sense of helplessness.

Relaxation is an antidote to both tension and stress. Also, it offers a distraction from pain. For some people, relaxation involves the regular use of a formal relaxation or meditation procedure, such the Relaxation Response, the Body Scan, Progressive Muscle Relaxation and the use of imagery. (For step by step instructions, see the article Stress Reduction: Five Practical Techniques.) 

Other relaxing activities include exercise, mindful breathing, baths and hot tubs, massage, rest breaks and listening to tapes or CDs. Integrating one or more periods of relaxation into your daily routine counteracts pain, stress and negative emotions.

Addressing Worry, Frustration & Depression
The experience of pain is intensified by emotions like worry, frustration and depression. Worry and frustration create muscle tension, which makes pain more intense. Relaxation procedures can reduce pain both directly by easing muscle tension and indirectly through reducing stress.

People who are depressed have a lower threshold for pain. Self-help strategies, sometimes in combination with medications, can help manage it. 

Treating Fatigue & Poor Sleep
Pain, fatigue and poor sleep are tightly connected. Fatigue deepens the experience of pain. When we feel tired, we experience pain more intensely, so if we reduce fatigue, we lessen pain.

Similarly, poor sleep intensifies pain, so improving sleep can help control pain. Of the three symptoms, poor sleep is often addressed first among people with ME/CFS and FM.

Heat, Cold & Massage
Heat, cold and massage can be used for temporary relief of pain.

Heat is best utilized for reducing the pain that results from muscle tension and inactivity. The warmth increases blood flow and thereby produces some relaxation, reducing pain and stiffness.

For localized pain, heating pads or hot packs are used frequently. For overall relief, people often use warm baths, soaks in a hot tub or lying on an electric mattress pad.

Cold treatments decrease inflammation by reducing blood flow to an area. They also may numb the areas that are sending pain signals. You might use gel packs, ice packs or bags of frozen vegetables. With both heat and cold, you should not use the treatment for more than 15 or 20 minutes at a time.

Massage of painful areas can also provide temporary relief from pain. Like heat, massage increases blood flow and can also relieve spasms. You can consider three different forms of massage: self-massage using your hands, massage using a handheld device, and professional massage.

If you use a massage therapist, ask her to be cautious and to check frequently on your pain sensitivity.

Problem Solving
You can gain some control over pain by identifying the situations that trigger or intensify pain and then taking steps to change them. For example, you might find that you are not able to keep up with household chores as you used to.

Using problem solving, you brainstorm a variety of solutions, such as spreading the chores out over several days, doing them on one day but taking rest breaks, and getting help from others, either family members or hired help. You then try a solution to see whether it works, evaluate and try again.

If you have a job and find that your pain increases when you work under deadlines, problem solving could take several forms. You might train yourself to take time to relax your muscles.

Looking at your situation more broadly, you may identify work overload as a recurring problem and consider reducing your hours, changing your responsibilities or taking time off from work.

Immersing yourself in pleasant thoughts and activities can lessen pain by providing distraction. Imagery can be especially helpful, as you visualize a pleasant scene, involving as many senses as possible.

If you want to transport yourself to the beach, see the light shimmering on the water, feel the warmth of the sun on your skin, hear the waves crashing and smell the mustard from the hotdogs.

Engaging in activities that bring pleasure can also provide distraction from pain. Examples include reading a book, watching a movie, taking a bath, listening to or playing music and spending time in nature.

Healthy Self-Talk
Thoughts can have a dramatic effect on our moods and, in turn, on our perceptions of pain. Negative thoughts can start a vicious cycle. An increase in symptoms may trigger negative thoughts like "I'll never get better" or "It's hopeless."

Such thoughts can then make us feel anxious, sad, angry and helpless, intensifying pain and triggering another round of negative thoughts and more muscle tension. This cycle can be reversed. It’s possible to learn to recognize and to change habitual thoughts to make them more positive and more realistic.

This well-researched approach, called Cognitive Therapy, can be found in books like Feeling Good by David Burns and Learned Optimism by Martin Seligman. Also, you can learn it from therapists trained in Cognitive Therapy. For an introduction, including examples, see the article Changing Self-Talk: A Cognitive Therapy Primer.


People with FM and ME/CFS often treat pain with medications. Because no medication is consistently helpful and because sometimes pain relievers lose effectiveness as the body becomes accustomed to them, multiple rounds of experimentation are often needed. Usually, patients are started on dosages that are a small fraction of normal dosage levels.

FM and ME/CFS patients who seek pain relief through medications usually begin with non-prescription products, such as aspirin and other over-the-counter pain relievers, such as Advil (ibuprofen), Aleve (naproxen) and Tylenol (acetaminophen). Prescription drugs that improve sleep can have a beneficial effect on pain as well.

Another category is anti-depressants that include amitriptyline, Prozac (fluoxetine) and Paxil (paroxetine). Also, NSRIs (Norepinephrine-Serotonin Reuptake Inhibitors) have been shown to be effective for pain, have fewer side effects, and usually remain effective after months of use.

These include Effexor (venlefaxine), Cymbalta (duloxetine), and Savella (milnacipran hydrochloride). The last two have been FDA approved for treating pain from fibromyalgia.

Yet another category is anti-epileptic drugs. The first drug of this type was Neurontin (gabapentin). More recently Lyrica (pregabalin) has been FDA approved for the treatment of fibropain.

Some people find help through the prescription medication Tramadol (aka Ultram, utracet, Ryzolt, and others). Tramadol has the strength of codeine but fewer adverse reactions and is rarely addictive.

It is very effective and safer for people with ME/CFS and fibromyalgia than narcotic medications, which are not recommended except through a referral to a pain management specialist.

Finally, there is Low Dose Naltexone. Recently, it has been recognized that glial cells in the brain can affect neurons. When activated or "angry," these glial cells sensitize neurons and magnify pain.

Serendipitously, it was found that a low dose of the narcotic antagonist naltexone could calm angry glial cells and reduce fibropain. Thus, the antidote for narcotic overdose has become a pain remedy!

Experience has shown that about 60% of people with fibropain will respond to Low Dose Naltrexone (LDN). Since LDN is a narcotic antagonist, one cannot take narcotics such as codeine, hydrocodone, oxycodone or even tramadol at the same time as LDN. Also, you have to wean off all narcotics for several days before starting LDN or risk withdrawal symptoms.

This is an off-label investigational use of naltexone, so LDN is neither covered by most insurers, nor is it available at most chain drug stores. Fortunately, it is inexpensively and easily obtained at most compounding pharmacies.

The usual dose is 5mg daily, in the morning. Side effects are unusual, although some individuals experience nausea or insomnia at first. Side effects can be minimized by starting with 1mg daily and increasing the dose slowly.

Many fibromyalgia patients also experience Myofascial Pain Syndrome (MPS), a pain condition localized in trigger points (specific locations in muscles or fascia), often in the neck or shoulders. MPS may be treated with medication, physical therapies, myofascial release techniques, and the injection of local anesthetics into the trigger points.

Some patients experience neuropathic or nerve pain, burning or electric shock sensations, felt most commonly in the hands and feet. This type of pain is often treated with anti-seizure medications, such as Neurontin or Lyrica.