Fibromyalgia and dysautonomia: towards a neurophysiological framework for personalized management

Fibromyalgia (FM) is a persistent, heterogeneous disorder characterized by widespread pain and multiple non-pain symptoms, including fatigue, cognitive dysfunction, gastrointestinal disturbance, dizziness and balance impairment. Increasing evidence suggests that autonomic dysfunction may contribute to this multisystem presentation, with abnormalities in heart rate variability (HRV), orthostatic cardiovascular regulation and postural orthostatic tachycardia syndrome (POTS) reported in patients with FM. This narrative review examines the evidence for dysautonomia in FM, its relationship with peripheral and central mechanisms, approaches to clinical assessment, and current and emerging strategies for mechanism informed management. A literature search was undertaken using PubMed/MEDLINE, Scopus and PEDro, supplemented by citation searching and relevant grey literature. The search incorporated literature addressing FM, dysautonomia and vestibular rehabilitation, with additional recent literature included to reflect emerging evidence. Evidence supports autonomic dysfunction in a substantial proportion of patients with FM, including reduced HRV, altered sympathovagal regulation, orthostatic intolerance and POTS. Peripheral small fiber pathology and alterations within central autonomic, sensory-processing and stress-response networks may contribute to dysautonomia, supporting interactions between peripheral, central and autonomic mechanisms. Autonomic symptom screening, orthostatic vital signs, HRV and, where indicated, formal autonomic and small fiber investigations may assist in identifying clinically relevant phenotypes. Current management includes lifestyle modification, exercise and rehabilitation, with pharmacological treatment where appropriate. Emerging approaches include HRV biofeedback, non-invasive vagal modulation, vestibular rehabilitation and rehabilitation tailored to the predominant physiological phenotype. Dysautonomia appears to represent a clinically meaningful component of FM in a subgroup of patients rather than a universal feature of the disorder. Recognition of autonomic, peripheral and central contributions may facilitate more targeted clinical assessment and mechanism informed management. Improved phenotyping and further investigation of therapies targeting specific autonomic abnormalities may support more personalized approaches to FM care.