Fibromyalgia (FM) is a long term condition that causes widespread pain throughout the body. Doctors used to use “tender points” to help them form a diagnosis. These are areas on the body that feel tender after pressure. However, recent guidelines have phased these out and introduced new diagnostic criteria.

The main features of FM are chronic pain (which may be mild or severe), extreme tiredness, and disrupted sleep. Depression or anxiety may also arise from FM’s ongoing impact on everyday life.

It is hard for healthcare providers to diagnose FM from the symptoms of pain alone. Many other factors should come into consideration while forming a diagnosis. For this reason, doctors no longer use the tender points described above to diagnose FM.

In this article, we explain what the tender points are and the current diagnostic criteria that have replaced them.

a doctor examining the elbow of a patient because it is one of the fibromyalgia tender pointsShare on Pinterest
Possible tender points of FM include the outer elbows, the upper chest, and the back of the head.

Doctors used to use the phrase “tender points” (or “trigger points”) to describe sensitive areas on the body that become painful with a standard amount of pressure to the area.

In the past, they would diagnose the condition according to a set of criteria that identified 18 tender points on the body. To qualify for a diagnosis of FM, a person had to experience tenderness in 11 of these tender points.

The previous tender points of FM included the following areas on both sides of the body:

  • the upper chest
  • the back of the head
  • the outer elbows
  • the knees
  • the hips
  • the tops of the shoulders

However, there were multiple issues with these criteria. For example, using tender points was actually contributing to the overdiagnosis of FM.

Also, people with FM may not experience constant pain. The pain may be intermittent, and it can even move to different areas of the body.

Other medical conditions, such as polymyalgia rheumatica, can also cause tenderness in these areas.

Many rheumatic diseases — such as Lyme disease, rheumatoid arthritis, lupus, and Sjogren’s syndrome — can also cause widespread pain and tender areas.

Another issue is that FM is not simply a pain condition. It can also cause cognitive symptoms, including memory problems, anxiety, and depression. FM can also contribute to fatigue and waking up feeling unrefreshed.

For this reason, a diagnosis of FM is more complicated than identifying pain at specific points on the body. In 2010, the American College of Rheumatology (ACR) updated their diagnostic guidelines to reflect this.

At this point, doctors slowly stopped relying on tender points to diagnose FM.

Doctors no longer use the tender points to diagnose FM.

As the medical community’s understanding of FM advanced, the ACR developed new criteria to aid diagnosis. These criteria are as follows.

Widespread pain index

These criteria do not rely on tender points that respond to pressure from a finger. Instead, they take into account the number of areas in which the individual has felt pain over the past week.

The doctor assesses these areas and generates a widespread pain index (WPI) score on a scale from 0 to19.

The areas that qualify include the:

  • hip
  • upper and lower back
  • shoulder girdle
  • upper and lower arm
  • upper and lower leg
  • chest
  • neck
  • abdomen
  • jaw

Some healthcare providers may also use these criteria to rule out other conditions.

Symptom severity scale

A healthcare provider may also use a symptom severity (SS) scale, which takes into account other FM symptoms, such as fatigue and depression. They will rank the severity of each symptom on a scale from 0 to 3, with 0 indicating no symptom at all and 3 indicating a severe presentation of this symptom.

On the same scale, doctors will also rank the presence of non-pain symptoms. Receiving a score of 0 indicates no other symptoms, whereas a 3 would suggest a large number of symptoms.

They will then combine these SS scores and establish a final score out of 12.

People who meet the following criteria are likely to have FM:

  • a WPI score of more than 7 out of 19 and an SS scale score of 5 or higher, or a WPI score between 3 and 6 and an SS scale score of 9 or higher
  • the presence of symptoms at a similar level for 3 months or longer
  • there is no other condition or disorder present that adequately explains the areas and extent of the pain

Some doctors use modified criteria in which they rank the presence of other symptoms as a yes or no choice, rather than having their patients describe the severity of these symptoms.

These criteria account far better for the presence of non-pain symptoms in people with FM.

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A person with FM may have difficulty sleeping.

As well as experiencing widespread pain, people with FM may also have headaches, difficulty sleeping, and fatigue. Depression, anxiety, and concentration problems are also possible symptoms.

Some people have many of these symptoms, while others may only have a few. Symptoms are also highly personal to each individual, so no single test can measure them.

Read more about flares of symptoms in people with FM.

When to see a doctor

It is hard to measure pain and fatigue because people may experience and report it differently.

Diagnosing FM is complex. People who suspect that they may have the condition should seek consultation with a doctor who is familiar with it and similar conditions.

As many symptoms of FM are general to begin with, it can be difficult to know when to see a doctor.

However, a person should see their healthcare provider if they feel widespread pain for more than a few weeks, especially if they are experiencing additional symptoms, such as trouble sleeping or concentrating.


FM is not a life threatening condition, but it can interfere with everyday function and quality of life. People with the condition may find that it can affect their employment, family, and social life.

Anxiety and depression may also be complications of FM, as withdrawing from activities due to symptoms can contribute to emotional issues.

Although there is currently no cure for FM, there are treatments that may decrease symptoms and improve quality of life. Certain strategies and self-help techniques can also support a person with FM.

Doctors often suggest making lifestyle changes to treat the symptoms of FM. However, they may prescribe medication if lifestyle changes are not effective enough.

These medications may include:

Pain medication

A doctor might recommend over-the-counter (OTC) pain medications, such as acetaminophen. The Food and Drug Administration (FDA) have also approved several medications to treat other conditions that are also suitable for FM.

Some drugs change a person’s brain chemistry to help control pain levels. These drugs include milnacipran and duloxetine.

Another medication, pregabalin, blocks nerve cells that play a role in the transmission of pain.

Some people with severe FM pain may become dependent on certain types of pain medication. For this reason, doctors usually do not recommend narcotic pain medications due to the possibility of dependency.

Find out about natural pain relief methods here.

Sleep medications

A healthcare professional might recommend various OTC and prescription medications to treat the sleep-related problems that occur due to FM.


In some cases, a doctor might prescribe antidepressants and antianxiety medications to reduce the anxiety, depression, and sleep symptoms of FM.

As well as medication, some complementary treatments may also help some people with FM.

For example, massage therapy, acupuncture, and yoga can all help a person better manage their physical and emotional symptoms.

There are several steps a person with FM can take to manage their symptoms at home, including:


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Gentle exercise may help ease symptoms of FM.

The National Fibromyalgia Association usually recommend exercise for people who have FM.

Some forms of aerobic exercise — such as walking, swimming, and biking — may improve symptoms.

If a person with FM wants to start an exercise regimen, they should start slowly and gradually increase their tolerance to exercise.

Effective sleep hygiene

Going to bed at the same time each night and waking at the same time every morning can help a person develop a regular sleep pattern. Doctors also recommend avoiding caffeine close to bedtime.

Taking these steps may reduce the impact of FM on sleep hygiene for some people.

Relaxation techniques

It is useful to find ways to relax each day. For example, deep breathing, meditation, and yoga can all be beneficial.

Relaxing can improve mood, decrease fatigue, and reduce pain.

Getting support

Accepting help from family and friends may help, as can seeking professional assistance from a counselor.

Support groups are also available through organizations such as the National Fibromyalgia Association.


My FM is getting extremely severe, and I am experiencing suicidal ideation. Are there any emergency measures for the instant relief of severe FM?


If a person is experiencing suicidal thoughts, it is imperative to seek counsel from a physician or psychologist. They can help.

There are currently no instant relief measures for the severe pain of FM. If the widespread pain suddenly becomes much worse, it is best to seek medical evaluation to rule out another cause of the pain.

A doctor may need to assess thyroid function to exclude thyroid disease, which may increase pain, and to exclude rheumatoid arthritis and vasculitis.

Nancy Carteron, MD, FACR Answers represent the opinions of our medical experts. All content is strictly informational and should not be considered medical advice.
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