Purpose of reviewPatients with fibromyalgia are at increased risk to experience increased and prolongedpostoperative pain. In this review, we will provide an overview of pathophysiologicalcharacteristics of fibromyalgia relevant for enhanced pain processing after surgery.Furthermore, we will present some potential treatment options in the perioperativeperiod based on specific symptoms of individual fibromyalgia patients to optimize theirpain management after surgery.Recent findingsRecent evidence points towards enhanced central nervous system sensitization anddecreased descending inhibition in patients with fibromyalgia. Even in patients withoutfibromyalgia, these two mechanisms are seen as major contributors to the severity ofacute and chronic pain states after surgery. Furthermore, other symptoms andcomorbidities such as anxiety, depression and somatization disorder, frequentlyassociated with fibromyalgia, are independently known to increase the risk of acute andprolonged pain after surgery. Therefore, an optimal treatment approach in theperioperative period should include substances and strategies targeting specificsymptoms in fibromyalgia patients to prevent or specifically reduce acute and prolongedpain after surgery. Such multimodal pain management in fibromyalgia patients in theperioperative period should include nonopioid analgesics, gabapentinoids,antidepressants, N-methyl-D-asparate antagonists and use of regional techniques whenappropriate.SummaryThe perioperative pain management of patients with fibromyalgia is challenging andshould include symptom-based approaches to target enhanced central sensitizationand decreased inhibition in these patients as well as their psychological syndromesaiming to decrease acute and prolonged pain after surgery.