FM, Hypothalamic dysfunction, fatigue, Sleep disorders, Pain, Central sensitization

Effective Treatment of Pain and Sleep in Fibromyalgia – A Comprehensive Clinical Approach

by Jacob Teitelbaum MD

Fibromyalgia is dramatically increasing in both prevalence and public awareness. Unfortunately, most standard physicians are only taught about three “Band-Aids” for pain: the medications Lyrica, Cymbalta, and Savella. The modestly effective, there is a bright spot. These companies are spending $210 million a year to increase public and physician awareness of this condition.

Although most people suffering with these conditions don’t get much help from their standard physician, CAM is highly effective. Our published placebo-controlled study (available on request from fatigueDoc@Gmail.com, along with free and very helpful treatment tools for practitioners) shows that 91% of people improve by using a comprehensive SHINE Protocol addressing Sleep, Hormones/Hypotension, Infections, Nutrition, and Exercise as able. This protocol resulted in an average 90% increased quality of life (p< .001 versus placebo).

In this article, we will discuss how to optimize sleep and eliminate pain.

Problems with Sleep and Pain – the Causes

Fibromyalgia represents an energy crisis caused by dozens of underlying contributing factors. This results in hypothalamic – pituitary axis dysfunction. The hypothalamus uses more energy for its size than any other area in the body, causing this to act like a circuit breaker that goes off-line when energy drops below a certain point. The hypothalamus is also the sleep center, resulting in problems both falling and staying asleep.

In fact, a simple and highly effective way to determine whether severe fatigue and widespread pain are being caused by fibromyalgia is to ask one simple question. “Can you get a good night sleep?” Most people with severe fatigue from other causes can sleep. The paradox of inability to sleep despite being exhausted points to hypothalamic dysfunction. This is true even if other conditions such as lupus or multiple sclerosis are present, as secondary fibromyalgia is common from autoimmune conditions and also needs to be addressed for the person to improve.

Meanwhile, it takes more energy for our muscles to relax than to contract. Though counterintuitive, this is why after a heavy workout our muscles go tight instead of loose and limp. Chronic muscle tightness results in myofascial pain, which is what initiates the fibromyalgia pain process.

Chronic pain from many causes can trigger the brain to amplify the pain. This is called central sensitization. A simple way to explain this to the people you treat is that pain is not an outside invader. Rather, it is like the oil light on a car’s dashboard telling us that something needs attention. When the pain does not result in getting what the body is needing, it gets amplified (central sensitization or “brain pain”).

For those that are interested, here’s my theory about what then occurs (okay to just skip to the next paragraph). Over time, the chronic nerve firing exhausts the energy in the nerves. I suspect the mechanism is that low energy in the nerves triggers elevated cyclic AMP levels. This then stimulates HCN2 gene ion channels, which triggers nerves to auto-fire (like the pacemakers in the heart). This causes pain and further depletes energy, making the problem chronic. Over time, the small nerve fibers start to shrink back (called small fiber neuropathy). This triggers not only pain but also orthostatic intolerance and dysautonomia.

So there is a cascade of events triggering multiple kinds of pain.

The standard medical approach to pain? Put a Band-Aid over the oil light or surgically remove it. Understandably, this results in a poor outcome. For example, research shows that NSAIDs cause 30,000 – 50,000 preventable US deaths a year, and overdoses from prescribed narcotics another 15,000.

A Better Approach to Pain

Our research has shown that if you give the body what it needs, the pain goes away. To extend the analogy, when you put oil in the car, the oil light goes out. The question is how to tell what the body is asking for.

Here Is your “Body’s Owner’s Manual” for doing so. The popular free Cures A-Z phone app also does this for hundreds of health conditions. I find that the vast majority of pain, even when severe and chronic, can be effectively treated with CAM.

Four Key Health Domains for Eliminating Pain

Most illnesses do best when these four key domains of health are addressed:

1. Biochemistry. This includes nutrition, herbals, and medications.

2. Biophysics. This Includes many Energy Healing approaches, including things such as acupuncture and NAET. An especially excellent one for pain is called Frequency Specific Microcurrent (www.FrequencySpecific.com).

3. Structural. This includes ergonomics, manipulation techniques, surgery, massage, and myofascial release. It also includes fascia release, which is a rapidly evolving and very powerful new area which combines energy and structural approaches.

4. Mind-Body. Unexpressed feelings can often be trapped in muscles. Emotional and physical trauma can also cause the fascia to get stuck in the “frozen” mode. Put simply, there is a reason why some people are called a “pain in the back” – or even lower!

Standard medicine uses only medications and surgery – a very small part of the entire healthcare toolkit. People do best when the entire healthcare toolkit is available, instead of just the medical “hammer.”

The Seven Key Types of Fibromyalgia Pain

Muscle (myofascial pain) from decreased energy in the muscles. When the muscle shortens, you get those tender knots in the belly of the muscle called trigger points, along with tender points. When the pain is localized, it often comes from muscle strain from poor ergonomics, uneven hip heights, or repetitive stress injury. Correcting these can be helpful.

When the pain is generalized, as in fibromyalgia, this reflects a body-wide energy crisis. Optimizing energy production with the SHINE Protocol is based on the groundbreaking work by Prof. Janet Travell, and has been shown in our research to be dramatically effective at decreasing pain. This occurs as improved energy conditions in the muscles allow them to relax. A free 10-minute quiz called the Energy Analysis Program at www.vitality101.com (see step three) can determine the causes of the low energy and tailor a comprehensive program to optimize energy production.

Chronic muscle shortening can also trigger both inflammation and strain of their attaching tendons.

The most effective single herbal mix that I have found for pain is called CuraPhen (by Euromedica – available through Emerson Ecologics). This mix of a unique highly absorbed curcumin, boswellia, DLPA, and nattokinase is the first thing I give people with chronic pain, and it has been a pain relief miracle. It can be taken with any pain medications. I will often add topical comfrey (TraumaPlant) and an herbal mix called the Pain Formula (ITI). Give the herbal mixes six weeks to see the full effect. All of these can be used in combination and along with any pain medications.

Nerve pain. As discussed above, this generally results from uncontrolled repetitive firing. Numerous medications can help this. Supplements such as lipoic acid 300-600 mg twice a day and acetyl L carnitine 1000 mg 2 to 3 times daily has been shown to help nerve pain over time as well. A good multivitamin is also helpful. Be sure it does not have over 45 mg of vitamin B6, as this can actually aggravate nerve pain. In general, the Daily Energy Infusion vitamin powder (by Integrative Therapeutics) is my favorite multivitamin for most people I treat. It contains over 50 pills worth of optimized levels of most nutrients lost in food processing (except iron and essential fatty acids). And it does so in only one low-cost drink instead of a handful of pills.

Especially helpful for diabetic neuropathy and likely other kinds of nerve pain is intravenous lipoic acid. Interestingly, when combined with low dose naltrexone (3– 4.5 mg at bedtime), the lipoic acid can be very helpful not only for neuropathy but even for late stage cancers. This was excellent work by Dr. Burt Berkson, and combining the lipoic acid IV and PO with LDN often resulted in marked regression of metastases.

One protocol is to give 600-800 mg alpha lipoic acid in 250 cc’s of normal saline over one hour three times a week ongoing for cancer, and until nerve pain resolves for neuropathy. Some will then give 1000 mg (and occasionally even up to 1500 mg) of the alpha lipoic acid IV monthly for maintenance. The main concern with higher doses is hypoglycemia, so have some D50 IV syringes available to address this if symptoms occur when using the IV lipoic acid. Oral alpha lipoic acid should be given 300 – 600 mg twice daily ongoing as well.

Central sensitization or brain pain. When pain becomes chronic, the brain starts to amplify the pain. This can occur in many if not most kinds of chronic pain. The mechanism is called microglial activation. The microglia are like the gardeners in our brain’s garden, tending the brain cells. Normally, they are quite mellow. But like a gardener who sees weeds, with chronic pain they start to go wild and become over active, stimulating brain pain.

Although many medications are now geared towards masking the pain of central sensitization, there are a few that can actually help to turn it off. These include low-dose naltrexone and the antibiotics doxycycline or minocycline (a tetracycline) 100 mg twice daily. This is one reason why doxycycline has been shown to be so effective in rheumatoid arthritis, and many chronic pain conditions including fibromyalgia, although this research has largely been ignored because of the medication’s low cost. For more on this amazing medicine for pain, cancer, and autoimmune illness, see the new book The Power of Honest Medicine: LDN, the Life-Changing Treatment for Autoimmune Diseases by Julia Schopick.

Give the naltrexone (from compounding pharmacies) 3-4.5 mg each night. If it disrupts sleep, start with 1 mg and increase by 1 mg every 2 to 4 weeks. If problematic even at lower doses, simply give it in the morning instead. It takes two months to see the full effects, and I will continue it ongoing. Dosing over 4.5 mg actually eliminate the effectiveness. The medication cannot be given if people are on narcotics (it does not block the narcotic effect at this low dose, but the LDN simply will not work), although it is unclear whether it will work if given with tramadol (Ultram).

Migraine headaches. This is due to blood vessels in the brain having difficulty regulating their ability to expand and contract. Interestingly, vitamin B2 400 mg a day has been shown to decrease migraine frequency by approximately 69% after six weeks. Vitamin B12 (200 – 500 µg) and magnesium 200 mg a day also markedly decrease migraine frequency. These can easily be found in high potency multivitamin such as the Energy Revitalization System vitamin powder or Clinical Essentials. Food sensitivities and shifts in estrogen and progesterone also play important roles in some cases. Suspect the latter when the migraines happen mostly around your menses and ovulation. Using an estrogen patch to give stable estrogen levels during those periods can have dramatic benefit.

Sinus headaches and irritable bowel syndrome. Both of these processes are most often due to Candida (fungal/yeast) infections. Unfortunately, the sinusitis is usually treated with antibiotics which actually makes the yeast problem worse in the long term, triggering chronic sinusitis. Most women are familiar with this when antibiotics trigger vaginal yeast infections.

A far more effective treatment for chronic sinus problems is using a good probiotic along with the medication Diflucan 200 mg a day for 6 – 12 weeks along with Caprylex by Douglas Labs. For the sinusitis, compounding pharmacies can make a sinusitis spray that includes antifungal and antibacterials (available by prescription by mail from ITC pharmacy in Colorado). This combination can be very helpful after 6 – 12 weeks.

The Diflucan plus Caprylex can also be very helpful for the irritable bowel syndrome, as in most cases this is secondary to Candida. In some cases though, the IBS will reflect a bacterial overgrowth in the small intestine. A simple marker? If the persons flatus has a sulfur smell (think “silent but deadlies” back in grade school), it is most likely bacterial (SIBO or Small Intestinal Bacterial Overgrowth). In these cases, and herbal mix called Ultra MFP Forte (two twice a day for one month) can be quite helpful as can the antibiotic rifaximin.

Allodynia. This is when light touch on the skin is painful. This results from an increase in a brain neurotransmitter chemical called NMDA and can improve with compounded topical pain creams including Ketamine and NMDA receptor antagonist medications such as Namenda.

Small fiber neuropathy. When chronic pain and central sensitization become prolonged, the small nerve fibers in the body may start to shrink back. This can also result in problems from low blood pressure and heart rate control called orthostatic intolerance and POTS. A simple one-minute quiz (you can request this from me at FatigueDoc@gmail.com) can effectively screen for these low blood pressure issues, and they are very treatable – although most physicians are not familiar with them. Interestingly, small fiber neuropathy seems to be associated with immune depletion and can respond well to intravenous gamma globulin as well as treating the underlying chronic infections and using the SHINE Protocol overall.

Fortunately, virtually all pain can be effectively treated using a mix of standard and holistic treatment options. The problem is not lack of effective treatment for pain, but rather inadequate physician education about the research.

Optimizing Sleep in Fibromyalgia

Sleep is when tissue repair and growth hormone release occur. A number of studies have confirmed that inadequate sleep results in pain simply not going away. So, helping the person to get seven to eight hours of good solid sleep at night despite their hypothalamic sleep center not working is critical.

No single treatment will be enough to achieve this. If you give a high enough dose of one treatment to keep them sleeping for eight hours, the person will be hung over into late afternoon. Instead, it is essential to use low doses of several treatments combined. The free practitioner treatment tools available from FatigueDoc@Gmail.com includes a detailed treatment checklist on sleep (and over a dozen other areas) listing both natural and prescription options. Here are my favorites:

Natural Options

1. The Revitalizing Sleep Formula (by Integrative Therapeutics). This mix of valerian, lemon balm, passionflower, hops, 5 HTP, and theanine is outstanding for sleep. Give 2 – 4 capsules at bed time

2. Terrific ZZZZ (by EuroPharma). An excellent mix of essential oils

3. Melatonin. Most have minimal effect here. An exception is Nature’s Bounty Dual Spectrum 5 Mg Melatonin (Amazon or Walgreens). This has both immediate and sustained release

4. Magnesium (If diarrhea I give the Jigsaw Sustained-Release Form) 150 – 200 mg at bedtime. Alternatively, a hot bath with 2 cups of Epsom salts (magnesium salts) an hour before bedtime can be very helpful for both pain and sleep

Medications

1. Ambien or Lunesta to help people fall asleep. These can have significant side effects (including sleepwalking and eating) as well as rebound insomnia when stopped. Nonetheless they can be very helpful. To help people stay asleep I add

2. trazodone (Desyrel) 25 – 50 mg

3. cyclobenzaprine (Flexeril) 2.5 – 5 mg

4. Neurontin 100 – 600 mg

5. Benadryl 12.5 – 50 mg

Although fibromyalgia requires a comprehensive protocol to see optimal results, the parts of the protocol above can result in dramatic improvement. The free Energy Analysis Program at www.Vitality101.com (step three) is a 10 minute quiz which can analyze the person’s symptoms, and even lab tests if available, to determine the main causes of their energy crisis and tailor a protocol to optimize their energy. By having the person fill out the symptom checklist that is part of the free treatment tools, your staff can enter the results into this program and generate a free detailed report that will make you look like a wizard! So, you now have all the tools you need to be a fibromyalgia expert – today!

Jacob Teitelbaum, MD, is the author of the best-selling From Fatigued to Fantastic!, Pain Free, 1,2,3!, and The Fatigue and Fibromyalgia Solution. He is the lead author of four studies on effective treatment for fibromyalgia and chronic fatigue syndrome.