What Actually Causes Fibromyalgia? The Mitochondrial, Mast Cell, and Small Fiber Neuropathy Mechanisms Standard Treatment Misses — What restoration looks like

A treatment approach anchored in the four-driver framework looks different from standard fibromyalgia care. The conventional medications continue where they are providing benefit and the side effect profile is acceptable. The upstream work proceeds in parallel. For Driver 1 (mitochondrial) cases: CoQ10 in ubiquinol form (200-400 mg daily); magnesium glycinate (400-600 mg daily, divided); riboflavin (100-400 mg daily); alpha-lipoic acid (300-600 mg daily); NAD+ precursor supplementation (nicotinamide riboside or NMN); sleep optimization and consistent meal timing because the compromised mitochondrial state cannot buffer disruptions; address the upstream drivers of the bioenergetic compromise (inflammation, CD38 induction, Fe-S cluster damage). For Driver 2 (mast cell) cases: mast cell stabilization (cromolyn, ketotifen, quercetin); H1 and H2 antihistamine combination where appropriate; low-histamine dietary trial (4-8 weeks with careful reintroduction); identify and address the Pattern A or Pattern B driver per the MCAS four-patterns framework. For Driver 3 (small fiber neuropathy) cases: skin biopsy confirmation where accessible (consider Therapath Lab or comparable); alpha-lipoic acid (well-evidenced for small fiber neuropathy at 600-1200 mg daily); B12 methylcobalamin (5000 mcg daily for at least 3 months); B1 thiamine, particularly benfotiamine form; magnesium and the broade