Fibromyalgia and Central Sensitisation Explained: What We Know, What We Do Not Know, and What May Help
Fibromyalgia is a long-term condition characterised by widespread pain, often accompanied by fatigue, unrefreshing sleep and difficulties with concentration or memory. Symptoms can substantially affect work, relationships, physical activity and everyday life.
There is no single blood test or scan that confirms fibromyalgia. Research suggests that altered processing of pain and other sensory information contributes in many people. This is often discussed using the terms central sensitisation and nociplastic pain. These concepts can be helpful, but they are not interchangeable, and no single mechanism fully explains every person’s symptoms.[1–5]
WHAT IS FIBROMYALGIA?
Fibromyalgia is a clinical condition involving pain in multiple areas of the body, together with a combination of symptoms that may include:
persistent fatigue;
waking feeling unrefreshed;
difficulties with concentration, memory or word-finding—sometimes called “fibro fog”;
tenderness or increased sensitivity to pressure; and
fluctuating physical function and activity tolerance.
Diagnosis is based on the history, symptom pattern and clinical assessment—not on one particular scan, blood test or tender-point examination. Commonly used diagnostic criteria consider the distribution of pain, symptoms lasting for at least three months, and the severity of fatigue, unrefreshing sleep and cognitive symptoms.[1]
Importantly, fibromyalgia can coexist with other conditions. Having fibromyalgia does not prevent someone from also having osteoarthritis, inflammatory arthritis, neuropathic pain, migraine, a sleep disorder or another medical condition. Similarly, a diagnosis of fibromyalgia should not automatically be used to explain every new symptom.[1]
The World Health Organization’s ICD-11 classification includes fibromyalgia syndrome under chronic widespread pain, which sits within the broader category of chronic primary pain. In this context, “primary” means that persistent pain has become a principal health condition in its own right. It does not mean that the pain is imaginary, purely psychological, unimportant or without a biological basis.[2]
WHAT IS CENTRAL SENSITISATION?
Central sensitisation is a scientific term describing increased responsiveness within pain-processing pathways in the spinal cord and brain. When these pathways become more responsive, sensory input may produce a stronger pain experience than it otherwise would.
This may contribute to:
allodynia, in which a normally non-painful sensation such as light touch or gentle pressure becomes painful;
hyperalgesia, in which a painful stimulus feels more painful than expected; and
pain or sensitivity that spreads beyond its original location.
An alarm system that has become unusually responsive is sometimes used as an analogy. The analogy is imperfect, but it helps explain how pain can persist or spread without requiring continuing damage in every painful body part.
Central sensitisation is not the same as anxiety, low resilience or “having a low pain threshold” in a dismissive sense. It refers to biological changes in nociceptive processing. Psychological, behavioural, social and environmental factors can nevertheless influence pain processing—as they can in every person experiencing pain.
There is currently no routine blood test, MRI scan or questionnaire that directly proves central sensitisation in an individual. Clinicians and researchers infer its possible presence from combinations of symptoms, examination findings and experimental measures. These indicators are not unique to fibromyalgia and should not be treated as a definitive diagnostic test.[3,4]
WHAT IS NOCIPLASTIC PAIN?
The International Association for the Study of Pain uses nociplastic pain as a mechanistic descriptor for pain in which altered nociception is thought to contribute and the pain is not fully explained by:
tissue injury or disease activating peripheral nociceptors; or
a lesion or disease of the somatosensory nervous system, as occurs in neuropathic pain.
Fibromyalgia is commonly regarded as a condition in which nociplastic mechanisms may be prominent. However:
nociplastic pain is a descriptor, not a separate disease;
it is not identical to central sensitisation;
it cannot be established simply because a scan is normal; and
nociplastic, nociceptive and neuropathic pain mechanisms can coexist in the same person.[3]
For example, a person with fibromyalgia may also have nociceptive knee pain from osteoarthritis or neuropathic leg pain from a nerve disorder. Each problem may require separate assessment and management.
HOW FIBROMYALGIA AND CENTRAL SENSITISATION ARE LINKED
Research involving groups of people with fibromyalgia has commonly identified:
increased sensitivity to pressure, heat or other experimental stimuli;
increased pain responses when a stimulus is repeated;
differences in the body’s own pain-inhibiting processes; and
differences in the activity or connectivity of brain networks involved in pain and sensory processing.[3–5]
These findings support altered pain processing as an important part of current models of fibromyalgia. However, several qualifications are important.
First, these are generally average differences between research groups. They cannot currently diagnose fibromyalgia in an individual or identify the precise cause of that person’s symptoms.
Second, similar findings can occur in other persistent pain conditions and are not specific to fibromyalgia.
Third, altered central processing does not exclude peripheral contributions. Local joint, muscle, nerve or other bodily input may still aggravate symptoms, and peripheral nervous-system abnormalities have been reported in some subgroups. Fibromyalgia is therefore better understood as a heterogeneous condition rather than as one disorder with one proven mechanism.[3–5]
Finally, the word “central” refers to the central nervous system. It does not mean that symptoms are “all in the mind” or under voluntary control.
WHY TESTS CAN BE NORMAL WHEN PAIN IS SEVERE
There is no routine blood test, X-ray or MRI scan that confirms fibromyalgia. Standard investigations are mainly designed to identify conditions such as structural injury, inflammation, infection, endocrine disease or identifiable nerve damage. They do not directly measure the complex processes involved in the experience and regulation of pain.
Consequently, investigations may be normal or may show common findings that do not adequately explain the extent of the symptoms. This does not mean that the pain is imagined, exaggerated or unimportant.
At the same time, normal test results do not, by themselves, establish fibromyalgia or prove central sensitisation. Diagnosis requires an appropriate history and clinical assessment. Depending on the presentation, a clinician may arrange targeted investigations to assess for alternative or coexisting conditions—for example, inflammatory disease, thyroid dysfunction, anaemia, muscle disease, neuropathy or a sleep disorder.
Fibromyalgia is therefore not simply “the diagnosis given when every test is normal”. Nor should it become a diagnostic stopping point when symptoms are new, focal, progressive or otherwise inconsistent with the person’s established pattern.[1,5]
SYMPTOMS BEYOND PAIN
Fibromyalgia is a multisymptom condition. Apart from widespread pain, common features include:
Fatigue: persistent lack of energy, feeling “wiped out” after modest activity, or reduced endurance that may not be fully relieved by rest.
Unrefreshing, non-restorative sleep: sleeping for an apparently adequate period but waking without feeling restored, insomnia, or frequent waking.
Cognitive symptoms: difficulties with attention, processing speed, memory or word-finding, so-called “fibro fog”.
Physical sensitivity: tenderness, stiffness or discomfort from pressure or touch; heightened sensitivity to noise, light, temperature, or chemicals.
Migraine, irritable bowel syndrome, pelvic pain, temporomandibular pain, anxiety and depression are also more commonly reported among people with fibromyalgia. These conditions are not present in everyone and should be assessed on their own merits.
Central sensitisation may contribute to pain and sensory sensitivity, but it should not be assumed to explain every associated symptom. Fatigue and cognitive difficulties, for example, may also be influenced by disrupted sleep, persistent pain, medication effects, mood symptoms, physical inactivity, autonomic factors and other medical conditions.[1,5]
WHAT CAN INFLUENCE SYMPTOMS AND TRIGGER FLARES?
Fibromyalgia symptoms commonly fluctuate. Factors that may worsen symptoms in some people include:
poor-quality or disrupted sleep;
physical or emotional stress;
illness or another pain condition;
abrupt increases in activity;
prolonged inactivity and loss of physical conditioning;
cycles of doing too much on a better day followed by a prolonged flare - the so-called “boom and bust” cycle;
medication adverse effects; and
untreated anxiety, depression or sleep disorders.
Stress or past trauma is associated with greater symptom burden in some studies, but neither is required for fibromyalgia to develop. A trauma history does not establish that pain is psychological, and psychological distress should not be assumed simply because a person has fibromyalgia.
Anxiety and depression may precede, accompany or follow persistent pain. When present, they deserve appropriate treatment in their own right—not because treating them proves that pain was psychological, but because mood, sleep, activity and pain can influence one another.
MANAGEMENT: AN INDIVIDUALISED MULTIMODAL APPROACH
There is no single established cure for fibromyalgia, and no treatment works for everyone. Nevertheless, some people achieve meaningful improvements in symptoms, activity, sleep and quality of life.
Management is generally most effective when it is individualised, introduced gradually and directed towards the symptoms and activities that matter most to the person. Guideline-supported components include the following.[6–8]
Education and a shared plan
A clear explanation of the diagnosis can reduce uncertainty and fear and support informed self-management. Education should validate the reality of the symptoms while avoiding messages that every sensation represents injury or that the person must simply ignore or push through pain.
Information about central sensitisation may be useful, but it should be presented as one part of current scientific understanding—not as proof of a single cause or a promise that the nervous system can be rapidly “reset”.
Individually tailored graded movement and exercise program
Exercise has the most consistent support across fibromyalgia guidelines, although the size of benefit varies and is often modest on average.
Appropriate options may include:
walking or cycling;
aquatic exercise;
resistance or strengthening exercise;
mobility and flexibility work; and
movement-based practices such as tai chi or yoga.
The appropriate starting point differs between individuals. Activity should generally begin at a manageable level and be adjusted according to symptoms, recovery and function. Rapid progression, rigid targets and a “no pain, no gain” approach may provoke flares and reduce adherence.
Pacing and activity regulation
Pacing involves balancing activity and recovery rather than alternating between prolonged inactivity and doing as much as possible on a better day. The aim is to establish a more sustainable level of activity and then build capacity gradually where possible.
Pacing should not mean avoiding all activity. It is a method of making activity more predictable and manageable.
Sleep assessment and treatment
Sleep problems can worsen pain, fatigue and concentration. Management may include sleep hygiene principles, such as maintaining regular sleep and wake times, addressing factors that disrupt sleep, and assessing for specific conditions such as obstructive sleep apnoea, restless legs syndrome, or medication-related sleep disturbance.
General sleep-hygiene advice is not always sufficient when a separate sleep disorder is present.
Psychological and behavioural therapies
Cognitive behavioural therapy, acceptance and commitment therapy approaches, and related therapies can help some people manage distress, improve coping, regulate activity and pursue meaningful goals despite symptoms. Benefits vary, and psychological therapy should be presented as one available component rather than as a compulsory treatment.
These approaches are not recommended because fibromyalgia is imagined. They are used because persistent pain affects—and is affected by—sleep, attention, mood, behaviour, relationships and participation in everyday life.
Medicines in selected circumstances
Selected medicines may help particular symptoms, such as pain, sleep disturbance or coexisting anxiety or depression. Benefits are usually modest on average, and adverse effects can limit their usefulness.
A medication trial should ideally have:
a defined target symptom or functional goal;
an agreed period for reviewing benefit;
monitoring for adverse effects and interactions; and
a plan to reduce or cease the medicine if meaningful benefit is not achieved.
Long-term opioid treatment is generally not recommended for fibromyalgia because evidence of sustained benefit is lacking and the risks can be significant. Anti-inflammatory medicines do not specifically treat fibromyalgia, although they may have a role for a separate inflammatory or nociceptive condition.
Similarly, injections, radiofrequency procedures and surgery do not treat fibromyalgia as a whole. A procedure may sometimes be appropriate for a separate, clearly identified pain condition, but that decision requires its own clinical assessment.
Identification of coexisting conditions
Treatment may be less effective if important coexisting problems remain unrecognised. Depending on the individual, these may include:
inflammatory or degenerative musculoskeletal disease;
neuropathic pain;
migraine;
sleep disorders;
endocrine or nutritional problems;
medication adverse effects; or
anxiety, depression or trauma-related symptoms.
Some people benefit from coordinated care involving their general practitioner and selected health professionals, such as a physiotherapist, exercise physiologist, psychologist, pharmacist, sleep clinician, rheumatologist or pain medicine physician. Not everyone requires every discipline.
WHEN IS FURTHER MEDICAL ASSESSMENT IMPORTANT?
People with an established diagnosis of fibromyalgia should still seek assessment when symptoms are new, substantially different or progressively worsening.
Features that should not automatically be attributed to fibromyalgia include:
visibly swollen or inflamed joints;
persistent fever, night sweats or unexplained weight loss;
progressive weakness or loss of coordination;
new focal numbness or other neurological changes;
significant changes in bladder or bowel function;
a new rash or other systemic symptoms; or
rapidly changing or highly localised pain.
The need for reassessment does not invalidate the fibromyalgia diagnosis. It recognises that fibromyalgia can coexist with other health conditions.
KEY MESSAGES
Fibromyalgia is a real and potentially disabling condition. Altered pain processing—and possibly central sensitisation—appears to contribute in many people, but it is not the only possible mechanism and cannot currently be confirmed by a routine clinical test.
Normal investigations do not make the pain less real, but they also do not prove fibromyalgia or central sensitisation. A careful clinical assessment remains important, particularly when symptoms change.
Management usually focuses on improving sleep, function, activity, participation and quality of life through an individualised combination of education, graded movement, pacing, psychological support where useful, selected medicines and treatment of coexisting conditions.
General information disclaimer: This article provides general educational information and does not replace individual medical assessment, diagnosis or treatment. The suitability and risks of any treatment depend on a person’s medical history, examination findings, other conditions, medicines and preferences. Seek prompt medical attention for severe, rapidly progressive or emergency symptoms.
Last medically reviewed: 13/08/2026.
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