Introduction

Fibromyalgia syndrome (FMS) is a chronic complicated rheumatic disorder characterized by widespread musculoskeletal pain, tenderness, fatigue, neuro-cognitive alterations, and sleep disturbances. Although these are the most common complaints, paresthesias, urinary system signs, abdominal pain, cramp, headache, dysmenorrhea-pelvic pain, and dizziness can also accompany the clinical picture. Fibromyalgia syndrome can have devastating effects on individuals because the clinical picture has the potential to negatively affect all aspects of life. Fibromyalgia syndrome can lead to sedentary behavior, functional difficulties, and various physical disabilities. All of these symptoms impair quality of life and result in depression and anxiety. The etiopathogenesis of FMS is complex and several hypotheses have been proposed on this subject [1–3].

Clinical observations show that FMS progresses with periods of flares and relative symptom alleviation. The frequency and duration of these periods show individual differences. It is quite difficult to provide a clear definition for flare. In a study of FMS patients, participants defined flare as an abrupt rise in symptoms to the point where it becomes impossible to perform daily living activities [4].

Fibromyalgia syndrome patients’ flare characteristics can differ. The flare manifestation can emerge as a substantial increase in the intensity of existing symptoms in some patients, while it can manifest as the appearance of new signs in others. Therefore, defining the FMS flare is critical for determining the clinical pathway to be followed afterward.

Is the clinician facing a real fibromyalgia flare?

The exacerbation of symptoms or the emergence of new findings in an FMS patient should be approached with suspicion first. This may be a flare, but newly onset secondary diseases or disorders may be causing exacerbation of symptoms or the occurrence of new complaints. Conditions that can be confused with the clinical picture of FMS are broadly classified as rheumatic, neurologic, non-rheumatic medical disorders, psychiatric abnormalities, and drug-related side effects. The coexistence of FMS with newly emerging or early-stage inflammatory rheumatic diseases can be inaccurately evaluated as a flare. Co-occurring endocrine (hypothyroidism, hyperparathyroidism, and vitamin D deficiency), gastrointestinal (celiac and Crohn’s disease) disorders, infections, and neurologic diseases (polyneuropathy and multiple sclerosis) complicate the interpretation of flare [5].

It should be kept in mind that the aforementioned disorders can occur during FMS patient follow-up. The drugs used, recent treatment modifications, and supplementary product preference should be examined in terms of adverse effects. Patients should be evaluated with detailed anamnesis and physical examination, and necessary tests should be requested in cases of doubt.

Causes of flare

Although many different factors have the potential to play a role in the process, the causes of FMS flares can be summarized as follows:

The most emphasized factor is stress, which can be regarded as an umbrella term. This term encompasses work and life stress, emotional extremes, family concerns, and travel-related doubts. There is evidence that stress responses can affect FMS flares. Fibromyalgia syndrome patients report exacerbation of symptoms in the days following excessive physical activity. Deterioration of sleep quality triggers FMS flares, sleep quality worsens further with increased disease activity and a vicious cycle occurs. Seasonal transition periods should be considered when encountering a patient with a suspected FMS flare. This patient group can be adversely affected by weather fluctuation. Furthermore, the patient should be questioned about recent dietary changes, and it should not be forgotten that the triggering factor may be present at this point [6, 7].

Management of fibromyalgia flares

There is no gold standard method for managing FMS flares. Although there are various treatment strategies, it is obvious that there will be individual differences in response to treatment. Therefore, it is crucial to individualize the treatment and determine the most appropriate approach for the patient.

Changing medical treatments is not always the best option. It is clear that drugs require a certain length of time to reach an effective dose. Nonetheless, medical treatment options will need to be evaluated during follow-ups. Education is one of the key components of flare management. It should be explained that this period is temporary and the flare period, which is a part of the FMS clinical process, is experienced. Physical activity modification and balancing daily living activities are also essential steps. Excessive physical activity should be avoided and rest times rather than complete inactivity should be established. This will require planning for daily living activities. Several relaxation techniques can be used to reduce the focus on exacerbated symptoms. Breathing exercise, massage, spa therapy, meditation approaches, mindfulness/mind-body therapy, and biofeedback techniques can be preferred for this purpose. Another suggestion for flare management is to strengthen social support [7–9].

One of the important issues to be emphasized is the disparities in European Alliance of Associations for Rheumatology (EULAR) recommendations for the non-pharmacological treatment approaches mentioned above. The EULAR provided weak recommendations for meditative approaches, mindfulness/mind-body therapy, and hydrotherapy/spa therapy. Furthermore, EULAR did not recommend biofeedback (weak against) or massage therapy (weak against) for FMS management [10]. This is due to the shortcomings in studies with a high level of evidence regarding these methods. In clinical practice, some FMS patients can benefit from these methods. Therefore, flare management in FMS should be individualized and it should be kept in mind that there is no standard protocol appropriate for all patients.

Conclusions

Flares can occur for a variety of reasons in FMS patients. There is no standard flare clinic for patients. While some patients have a clinical picture of worsening current symptoms, there is also a patient group in which new signs arise. First of all, it should be ensured that the clinical picture encountered is a flare. It should be noted that numerous concomitant disorders may mimic an FMS flare. Although there are several approaches for flare management, individualization of treatment is a requirement.