apply a load to their body using weights, elastic band, body weight or other measures. two meta-analyses on fibromyalgia have shown that resistance training can reduce anxiety and depression and one found that it improves quality of life. the dosage of resistance exercise for women with fibromyalgia was studied in a 2022 meta-analysis. effective dosages were found when exercising twice a week, for at least eight weeks. symptom improvement was found for even low dosages such as 1–2 sets of 4–20 repetitions. most studies use moderate exercise intensity of 40% to 85% one-repetition maximum. this level of intensity was effective in reducing pain. some treatment regimes increase the intensity over time (from 40% to 80%), whereas others increase it when the participant is able to perform 12 repetitions. high-intensity exercises may cause lower treatment adherence. meditative a 2021 meta-analysis found that meditative exercise programs (tai chi, yoga, qigong) were superior to other forms of exercise (aerobic, flexibility, resistance) in improving sleep quality. other meta-analyses also found positive effects of tai chi for sleep, fibromyalgia symptoms, and pain, fatigue, depression and quality of life. these tai chi interventions frequently included 1-hour sessions practiced 1-3 times a week for 12 weeks. meditative exercises, as a whole, may achieve desired outcomes through biological mechanisms such as antioxidation, anti-inflammation, reduction in sympathetic activity and modulation of glucocorticoid receptor sensitivity. aquatic several reviews and meta-analyses suggest that aquatic training can improve symptoms and wellness in people with fibromyalgia. it is recommended to practice aquatic therapy at least twice a week using a low to moderate intensity. other limited evidence suggests vibration training in combination with exercise may improve pain, fatigue, and stiffness. medications a few countries have published guidelines for the management and treatment of fibromyalgia. as of 2018, all of them emphasize that medications are not required. however, medications, though imperfect, continue to be a component of treatment strategy for fibromyalgia patients. the german guidelines outlined parameters for drug therapy termination and recommended considering drug holidays after six months. approved medications health canada and the us food and drug administration (fda) have approved pregabalin and duloxetine for the management of fibromyalgia. the fda also approved milnacipran, but the european medicines agency refused marketing authority. antidepressants antidepressants are one of the common drugs for fibromyalgia. a 2021 meta-analysis concluded that antidepressants can improve the quality of life for fibromyalgia patients in the medium-term. as of 2018, the only tricyclic antidepressant (tca) that has sufficient evidence is amitriptyline. for most people with fibromyalgia, the potential benefits of treatment with the serotonin and noradrenaline reuptake inhibitors (snri) duloxetine and milnacipran and the tcas, such as amitriptyline, are outweighed by significant adverse effects (more adverse effects than benefits), however, a small number of people may experience relief from symptoms with these medications. in addition, while amitriptyline has been used as a first line treatment, the quality of evidence to support this use and comparison between different medications is poor. very weak evidence indicates that a very small number of people may benefit from treatment with the tetracyclic antidepressant mirtazapine, however, for most, the potential benefits are not great and the risk of adverse effects and potential harm outweighs any potential for benefit. the length of time that antidepressant medications take to be effective at reducing symptoms can vary. any potential benefits from the antidepressant amitriptyline may take up to three months to take effect and it may take between three and six months for duloxetine, milnacipran, and pregabalin to be effective at improving symptoms. some medications have the potential to cause withdrawal symptoms when stopping so gradual discontinuation may be warranted particularly for antidepressants and pregabalin. there is tentative evidence that the benefits and harms of selective serotonin reuptake inhibitors (ssris) appear to be similar. ssris may be used to treat depression in people diagnosed with fibromyalgia. tentative evidence suggests that monoamine oxidase inhibitors (maois) such as pirlindole and moclobemide are moderately effective for reducing pain. very low-quality evidence suggests pirlindole as more effective at treating pain than moclobemide. side effects of maois may include nausea and vomiting. central nervous system depressants central nervous system depressants include drug categories such as sedatives, tranquilizers, and hypnotics. a 2021 meta-analysis concluded that such drugs can improve the quality of life for fibromyalgia patients in the medium-term. anti-seizure medication the anti-convulsant medications gabapentin and pregabalin may be used to reduce pain. there is tentative evidence that gabapentin may be of benefit for pain in about 18% of people with fibromyalgia. it is not possible to predict who will benefit, and a short trial may be recommended to test the effectiveness of this type of medication. approximately 6/10 people who take gabapentin to treat pain related to fibromyalgia experience unpleasant side effects such as dizziness, abnormal walking, or swelling from fluid accumulation. pregabalin demonstrates a benefit in about 9% of people. pregabalin reduced time off work by 0.2 days per week. cannabinoids cannabinoids may have some benefits for people with fibromyalgia. however, as of 2022, the data on the topic is still limited. cannabinoids may also have adverse effects and may negatively interact with common rheumatological drugs. opioids the use of opioids is controversial. as of 2015, no opioid is approved for use in this condition by the fda. a 2016 cochrane review concluded that there is no good evidence to support or refute the suggestion that oxycodone, alone or in combination with naloxone, reduces pain in fibromyalgia. the national institute of arthritis and musculoskeletal and skin diseases (niams) in 2014 stated that there was a lack of evidence for opioids for most people. the association of the scientific medical societies in germany in 2012 made no recommendation either for or against the use of weak opioids because of the limited amount of scientific research addressing their use in the treatment of fm. they strongly advise against using strong opioids. the canadian pain society in 2012 said that opioids, starting with a weak opioid like tramadol, can be tried but only for people with moderate to severe pain that is not well-controlled by non-opioid painkillers. they discourage the use of strong opioids and only recommend using them while they continue to provide improved pain and functioning. healthcare providers should monitor people on opioids for ongoing effectiveness, side effects, and possible unwanted drug behaviors. a 2015 review found fair evidence to support tramadol use if other medications do not work. a 2018 review found little evidence to support the combination of paracetamol (acetaminophen) and tramadol over a single medication. goldenberg et al suggest that tramadol works via its serotonin and norepinephrine reuptake inhibition, rather than via its action as a weak opioid receptor agonist. a large study of us people with fibromyalgia found that between 2005 and 2007 37.4% were prescribed short-acting opioids and 8.3% were prescribed long-acting opioids, with around 10% of those prescribed short-acting opioids using tramadol; and a 2011 canadian study of 457 people with fm found 32% used opioids and two-thirds of those used strong opioids. topical treatment capsaicin has been suggested as a topical pain reliever. preliminary results suggest that it may improve sleep quality and fatigue, but there are not enough studies to support this claim. unapproved or unfounded sodium oxybate increases growth hormone production levels through increased slow-wave sleep patterns. however, this medication was not approved by the fda for the indication for use in people with fibromyalgia due to the concern for abuse. the muscle relaxants cyclobenzaprine, carisoprodol with acetaminophen and caffeine, and tizanidine are sometimes used to treat fibromyalgia; however, as of 2015 they are not approved for this use in the united states. the use of nsaids is not recommended as first line therapy. moreover, nsaids cannot be considered as useful in the management of fibromyalgia. very low-quality evidence suggests quetiapine may be effective in fibromyalgia. no high-quality evidence exists that suggests synthetic thc (nabilone) helps with fibromyalgia. nutrition and dietary supplements nutrition is related to fibromyalgia in several ways. some nutritional risk factors for fibromyalgia complications are obesity, nutritional deficiencies, food allergies and consuming food additives. the consumption of fruits and vegetables, low-processed foods, high-quality proteins, and healthy fats may have some benefits. low-quality evidence found some benefits of a vegetarian or vegan diet. although dietary supplements have been widely investigated in relation to fibromyalgia, most of the evidence, as of 2021, is of poor quality. it is therefore difficult to reach conclusive recommendations. it appears that q10 coenzyme and vitamin d supplements can improve pain and quality of life for fibromyalgia patients. q10 coenzyme has beneficial effects on fatigue in fibromyalgia patients, with most studies using doses of 300 mg per day for three months. q10 coenzyme is hypothesized to improve mitochondrial activity and decrease inflammation. vitamin d has been shown to improve some fibromyalgia measures, but not others. a review article including four studies with 98 patients found that melatonin treatment has several positive effects on fibromyalgia patients, including the improvement of sleep quality, pain, and disease impact. no major adverse events were reported. psychotherapy due to the uncertainty about the pathogenesis of fm, current treatment approaches focus on management of symptoms to improve quality of life, using integrated pharmacological and non-pharmacological approaches. there is no single intervention shown to be effective for all patients. in a 2020 cochrane review cognitive behavioral therapy (cbt) was found to have a small but beneficial effect for reducing pain and distress but adverse events were not well evaluated. cbt and related psychological and behavioural therapies have a small to moderate effect in reducing symptoms of fibromyalgia. effect sizes tend to be small when cbt is used as a stand-alone treatment for fm patients, but these improve significantly when cbt is part of a wider multidisciplinary treatment program. a 2010 systematic review of 14 studies reported that cbt improves self-efficacy or coping with pain and reduces the number of physician visits at post-treatment, but has no significant effect on pain, fatigue, sleep, or health-related quality of life at post-treatment or follow-up. depressed mood was also improved but this could not be distinguished from some risks of bias. a 2022 meta-analysis found that cbt reduces insomnia in people with chronic pain, including people with fibromyalgia. sleep hygiene interventions, however, were not as effective. patient education patient education is recommended by the european league against rheumatism (eular) as an important treatment component. as of 2022, there is only low-quality evidence showing that patient education can decrease pain and fibromyalgia impact. sleep hygiene interventions show low effectiveness in improving insomnia. manual therapy a 2021 meta-analysis concluded that massage and myofascial release diminish pain in the medium-term. as of 2015, there was no good evidence for the benefit of other mind-body therapies. acupuncture a 2013 review found moderate-level evidence on the usage of acupuncture with electrical stimulation for improvement of the overall well-being. acupuncture alone will not have the same effects, but will enhance the influence of exercise and medication in pain and stiffness. electrical neuromodulation several forms of electrical neuromodulation, including transcutaneous electrical nerve stimulation (tens) and transcranial direct current stimulation (tdcs), have been used to treat fibromyalgia. in general, they have been found to be helpful in reducing pain and depression and improving functioning. transcutaneous electrical nerve stimulation (tens) transcutaneous electrical nerve stimulation (tens) is the delivery of pulsed electrical currents to the skin to stimulate peripheral nerves. tens is widely used to treat pain and is considered to be a low-cost, safe, and self-administered treatment. as such, it is commonly recommended by clinicians to people suffering from pain. on 2019, an overview of eight cochrane reviews was conducted, covering 51 tens-related randomized controlled trials. the review concluded that the quality of the available evidence was insufficient to make any recommendations. a later review concluded that transcutaneous electrical nerve stimulation may diminish pain in the short-term, but there was uncertainty about the relevance of the results. preliminary findings suggest that electrically stimulating the vagus nerve through an implanted device can potentially reduce fibromyalgia symptoms. however, there may be adverse reactions to the procedure. noninvasive brain stimulation noninvasive brain stimulation includes methods such as transcranial direct current stimulation and high-frequency repetitive transcranial magnetic stimulation (tms). both methods have been found to improve pain scores in neuropathic pain and fibromyalgia. a 2023 meta analysis of 16