"In patients who do not have mild disease that responds to educational measures and exercise alone, we recommend the addition of medications (eg,amitriptyline, duloxetine, milnacipran, or pregabalin) as the next step for the treatment of the symptoms associated with fibromyalgia, rather than nonpharmacologic measures alone (Grade 1A). In general, drugs should be started at low doses and should be built up slowly. (See 'Medications'above.)
In patients who do not respond to trials of low-dose tricyclics or who have intolerable side effects, the choice of medications is guided by patient preference, by the patient’s symptoms, and by comorbidities. (See 'Medications' above.)
In patients with more severe problems with sleep, we suggest treatment with pregabalin taken at bedtime (Grade 2C). Treatment is initiated at a dose of 25 to 50 mg at bedtime and is adjusted upwards as tolerated to 300 to 450 mg/day. Gabapentin is an acceptable alternative for patients for whom cost or regulatory constraints limit the availability of pregabalin. (See 'Anticonvulsants (alpha2-ligands)' above and 'Pregabalin' above and'Gabapentin' above.)."