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Fibromyalgia is a chronic pain syndrome that is considered a pain processing disorder; its pathophysiology is not completely understood. The estimated prevalence in the general population varies from 0.5% to 12%, depending on the population studied and diagnostic criteria used. It is more common in females than males. There is no diagnostic laboratory test. The two currently used diagnostic methods are scoring criteria from the American College of Rheumatology (ACR) and the Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks (ACTTION)-American Pain Society (APS). These diagnostic criteria include chronic widespread pain of at least 3 months' duration plus poor sleep and/or fatigue and other somatic symptoms. Other pain syndromes also should be considered in the differential diagnosis. A multimodal, targeted symptom management approach that emphasizes self-management is recommended. Nonpharmacotherapies include patient education, exercise, and cognitive behavior therapy. Pharmacotherapy should be based on predominant symptoms. Amitriptyline and pregabalin are effective for management of pain, fatigue, and sleep issues. Milnacipran (Savella) is effective for pain and fatigue. Duloxetine is effective for management of pain and depression. There is no evidence of benefit of analgesics. Common comorbidities, such as regional pain conditions and mental disorders, should be addressed.

Myofascial pain syndrome (MPS) is a regional musculoskeletal pain disorder characterized by trigger points within the muscle or fascia. There are no universally accepted diagnostic criteria. Diagnosis currently is based on a physical examination finding of at least one localized trigger point that, when palpated, recreates the pain at the site or produces pain away from the site in a referral pattern. MPS is thought to be related to sustained muscle contraction from under- or overuse. This syndrome commonly coexists with other chronic pain conditions, including fibromyalgia. The difference between MPS and fibromyalgia is that MPS involves localized pain with discrete areas of tenderness, whereas fibromyalgia symptoms are more diffuse and widespread. Most management recommendations for MPS are based on low-quality clinical trials or expert opinion. A multimodal approach is recommended, involving patient education, exercise, behavior modification, pharmacotherapy, and procedural interventions. Commonly used drugs include topical analgesics, nonsteroidal anti-inflammatory drugs, and muscle relaxants. Procedural interventions include manual therapy (eg, deep tissue massage, spray and stretch technique, myofascial release), dry needling, trigger point injections, onabotulinumtoxinA injections, acupuncture, kinesiology tape, transcutaneous electrical nerve stimulation, extracorporeal shockwave therapy, and low-level laser therapy. Symptoms often resolve with these interventions if they are used early in the course of the condition. As MPS enters the chronic stage, it becomes increasingly refractory to treatment.

Neuropathic pain affects 7% to 10% of the population and has major effects on quality of life. It is defined as pain caused by a lesion or disease of the somatosensory nervous system and may be central or peripheral. Diagnostic testing may yield inconclusive or inconsistent results, so physicians often rely on clinical judgment based on the history and physical examination findings. Questionnaires and scoring systems can aid in diagnosis. Neuropathic pain is differentiated from other types of chronic pain by abnormal sensory symptoms, such as shooting pain, burning pain, or numbness. It is difficult to manage and can be accompanied by mood and sleep disturbances. Referral for psychotherapy may be useful for these patients. Nonpharmacotherapy options include mindfulness training, transcutaneous electrical nerve stimulation, and massage. Acupuncture also may be effective, but the data are mixed. Topical drugs (eg, lidocaine, capsaicin), gabapentinoids, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors are considered first-line drugs. Tramadol is considered a second-line drug, but may considered first-line for certain patients. For persistent pain, physicians can consider referring patients to a pain specialist for nerve blocks or other procedural interventions. Opioids may be considered for refractory pain, but their additional benefit has been shown to be modest compared with those of other treatments.

Complex regional pain syndrome (CRPS) is a chronic pain condition characterized by intense pain, usually in a body region that has experienced trauma, and autonomic and inflammatory features. It most commonly develops after an arm or leg injury. Patients typically present with extreme hyperalgesia and/or allodynia. The Budapest Criteria are used to make this clinical diagnosis. Prompt diagnosis and aggressive management are critical because long-term outcomes are improved when treatment is initiated soon after symptom onset. The primary management options are rehabilitation and physical therapy, including such approaches as progressive tactile stimulation, normalization of movement to prevent limited range of motion, and others. No drugs are approved by the Food and Drug Administration (FDA) for CRPS management, but some evidence supports the use of drugs used to manage other types of neuropathic pain (eg, gabapentin, tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors). Nonsteroidal anti-inflammatory drugs also are used, and corticosteroids, bisphosphonates, ketamine, and other drugs can be helpful, particularly for early-stage CRPS. When pain severity prevents patients from participating in rehabilitation, referral to a pain specialist is warranted for consideration of procedural interventions, including sympathetic nerve blockade and spinal cord stimulation.

Becoming ill while traveling is an unfortunate but common event, with gastrointestinal, febrile, dermatologic, and respiratory symptoms predominating. However, many illnesses acquired abroad can be prevented or controlled with evidence-based preventive measures and judicious use of appropriate self-care and local medical care. It is important that travelers know how to use international medical care and are aware of available tools to help them identify appropriate medical care in another country. Discussion of evacuation insurance is a crucial part of the pretravel medical evaluation. Epidemiology, prevention, and management guidelines of common travel-related illnesses, such as travelers diarrhea and febrile illnesses, should be addressed. Traveler counseling regarding the early management of serious but underrecognized considerations, such as accident-related trauma, sexual health, and mental health, should be included in the pretravel assessment. Important aspects of appropriate counseling and management of the traveler returning from an extended visit abroad include addressing reverse culture shock and evaluating symptoms that could be part of a delayed presentation of an illness acquired abroad.

Risks during travel depend on travelers' comorbidities and trip activities. Travel on cruise ships, for pilgrimages or large events, or into the wilderness carries unique risks. Asking travelers about what activities they have planned or may do during travel can tailor the subsequent pretravel counseling points and help guide decisions about vaccines and drugs. Some prescriptions (eg, doxycycline for prophylaxis against leptospirosis) depend on the planned activities while abroad. Travelers should be prepared for potential emergencies and should be encouraged to research unique customs and laws in the countries they plan to visit before departure. The US State Department's website has resources that Americans traveling abroad should be familiar with, including information about the laws and customs of the destination country. It is important that travelers investigate the different insurance options or coverages before a trip, in case emergencies arise.

Before the COVID-19 pandemic, international travel was increasing at a brisk rate. After a lull, it is picking up again and predicted to continue to climb as it had previously. International travel presents some unique health hazards, including infectious diseases, chronic disease exacerbation, environment-related illness, accidental injuries, and transportation-related illness. Many travelers appropriately seek medical consultation for advice and interventions to decrease their health risks during travel. The pretravel consultation consists of risk identification and preventive interventions. Although these consultations traditionally have occurred with infectious disease specialists, family physicians can and should provide this care. Pretravel consultations should review a patient's medical conditions, how travel can affect them, and what the patient can do to address medical needs that may arise while abroad. Balancing the risks likely to be encountered with the individual traveler's risk tolerance, patients and family physicians can collaboratively develop a strategy to mitigate these risks and increase the likelihood of an uneventful (and enjoyable) sojourn.

Certain conditions (eg, asthma, diabetes, physical disability, immunocompromise, severe allergies, pregnancy) may increase the risk of travel, but do not necessarily preclude it. Typical age-related physiologic changes also can increase the chances of serious injury or illness. For example, infection with malaria can result in more severe parasitemia in HIV-positive, pregnant, or older travelers. Physicians should evaluate each traveler as an individual, assessing risk tolerance and helping patients decide if the benefits outweigh the definite and potential costs. Extremes of climate and altitude, changes in time zones, and unfamiliar foodstuffs should be given particular attention. The well-prepared traveler should explore options for supplemental insurance, obtain necessary medical records and supplies (including their regular drugs and an appropriate first aid kit), receive education on how to recognize and what to do in the event of a medical emergency, and understand where to find high-quality care abroad.