Signs and Symptoms

• Severe fatigue that comes on suddenly, especially after you have had the flu
• Low-grade fever (100.4°F/38°C) and chills
• Sore throat and swollen lymph glands in the neck or armpits
• Muscle and joint aches without any swelling
• Headaches
• Sleep that does not feel refreshing
• Feeling like you are in a fog and not being able to concentrate or remember
• Mood changes

What Causes It?

The cause of CFS is unknown, but a virus or an immune system reaction may be responsible. Preliminary research suggests herpes infection, for example, may trigger CFS. Risk factors include extreme stress or anxiety, flu-like illness that does not completely go away, poor eating habits, and psychological conditions, such as obsessive compulsive disorder, neuroticism, and perfectionism. Depression can make the condition worse and make it last longer.

What to Expect at Your Provider's Office

There is no laboratory test for chronic fatigue syndrome. But your health care provider may use tests to rule out other illnesses. Your provider will go over your symptoms, check your medical history, and do a physical examination.

If you have CFS, your provider may prescribe drugs to treat your symptoms, or suggest herbs, vitamins, or dietary changes to help you. Get plenty of rest, exercise regularly, and learn to pace yourself. Often this combination of treatments will help you get better.

If the usual treatments do not work, your provider may check for other conditions that can cause symptoms similar to those of CFS.

Treatment Options

CFS is a stressful disease. It is important to get emotional support, as well as treat your symptoms. Studies show that psychological support, including cognitive behavioral therapy, can help treat symptoms of chronic fatigue syndrome.

Although there is no cure, physicians may treat symptoms with medications, such as antidepressants and anti-anxiety drugs. Pain relievers and anti-inflammatory drugs help relieve muscle and joint aches. Support groups and stress management techniques can help you cope with the disease.

Drug Therapies

Antidepressants. In addition to relieving depression, these drugs can reduce fatigue and muscle tension, and improve sleep. Side effects vary. Antidepressants often prescribed for chronic fatigue include:

• Tricyclics: amitriptyline (Elavil), desipramine (Norpramin), notriptyline (Pamelor)
• Selective serotonin reuptake inhibitors (SSRIs): citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft)

Anti-anxiety medications (benzodiazepines). Side effects vary. Alprazolam (Xanax) or lorazepam (Ativan) are among those prescribed.

Antihistamines. Relieve allergy like symptoms. Side effects include drowsiness and headache.

Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs help relieve pain. These drugs include naproxen (Aleve) and ibuprofen (Advil, Motrin). Side effects can include stomach bleeding when used for a long period of time.

Acetaminophen (Tylenol). Another pain reliever. Side effects can include kidney and liver damage when taken in large doses.

Stimulants. Improve fatigue and concentration. These drugs include methylphenidate (Ritalin, Concerta). People whose fatigue is less chronic tend to respond better.

Complementary and Alternative Therapies

Eating a healthy diet, and using herbs and homeopathic remedies as recommended, may help reduce the debilitating symptoms of CFS, and may improve overall energy. Counseling, support groups, meditation, yoga, and progressive muscle relaxation are stress management techniques that may help as well.

Lifestyle

• Save your energy. Your doctor may suggest that you slow down and pace yourself, so that you do not overdo it one day and pay for it the next. The goal is to maintain a steady, moderate amount of activity that includes regular exercise.
• Get regular exercise. Your doctor may suggest that you see a physical therapist to create an appropriate exercise program. At least one study shows that people with CFS who exercise have fewer symptoms than those who do not exercise.
• Reduce stress. Stress can make CFS symptoms worse. Guided meditation or deep breathing may help you relax. Studies show Qigong, in particular, helps reduce symptoms of fatigue and poor mental functioning.

Nutrition and Supplements

Avoid refined foods, sugar, caffeine, alcohol, and saturated fats. Eat more fresh vegetables, legumes, whole grains, protein, and essential fatty acids found in nuts, seeds, and cold-water fish.

The following supplements may help reduce symptoms of CFS. Supplements may not be appropriate for every patient, and some may have side effects and/or interact with other medications. Ask your doctor before taking a supplement and work with someone knowledgeable in complementary and alternative medicine therapies.

• Magnesium may help reduce fatigue. But studies show mixed results. Too much magnesium causes diarrhea. To correct this problem, gradually reduce the amount you are taking. It is sometimes combined with malic acid (600 mg, twice per day) to boost energy. Magnesium can alter blood pressure and interfere with certain medications.
• Omega-3 fatty acids , such as those found in fish oil may also help reduce fatigue. Studies show that people with CFS have lower ratios of omega-3 to omega-6 fatty acids. Omega-3 fatty acids may increase the risk of bleeding, especially if you also take blood thinners such as clopidogrel (Plavix), warfarin (Coumadin), or aspirin.
• NADH , a naturally-occurring chemical involved in energy production in the body. One small study showed it might help reduce symptoms of CFS. But more research needs to be done.
• DHEA , a hormone produced by the body that may improve energy levels. Your body uses DHEA to make testosterone and estrogen. It is truly a hormone rather than a supplement, and should never be taken without a doctor's prescription. DO NOT use DHEA if you have or are at risk for breast cancer, prostate cancer, or any other hormonally-influenced illness. DO NOT take DHEA if you are pregnant or breastfeeding. People with diabetes, high cholesterol, liver disease, or bipolar disorder should not take DHEA. DHEA interacts with many medications, including antidepressants and ant-anxiety medications.
• Vitamin B12 has been shown to improve energy in people who are not getting enough B12. It is not clear whether it will help in cases of CFS. Oral supplements do not work as well as injections.
• Beta-carotene to strengthen immune function. Some studies suggest that smokers should not take beta-carotene. Beta-carotene may interact with some drugs used to treat high cholesterol.
• L-carnitine may support energy production in the cells. L-carnitine may alter blood pressure. Tell your doctor about any kidney issues you may have, or if you have a history of seizures. People who take thyroid hormone or blood thinners should ask their doctor before taking L-carnitine.
• Vitamin D. Although vitamin D is not used specifically to treat CFS, not getting enough vitamin D may make symptoms worse. Vitamin D can be toxic in extremely high doses.
• Melatonin has been shown to improve fatigue symptoms among people with CFS. Melatonin may interact with certain medications, including some psychiatric medications. Speak to your physician.

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. However, herbs can trigger side effects and interact with other herbs, supplements, or medications. For these reasons, take herbs only under the supervision of a health care provider.

Unless otherwise indicated, make teas with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups per day. You may use tinctures alone or in combination as noted.

Herbs that may help with symptoms of chronic fatigue include:

• Ginseng ( Panax ginseng ) may help improve energy. One test tube study found that ginseng and echinacea increased the immune response in cells taken from people with CFS. However, no studies have been done where people took ginseng for CFS. Ginseng can increase the risk of bleeding, especially if you already take blood thinners, such as clopidogrel (Plavix), warfarin (Coumadin), or aspirin. Ginseng also may interact with several drugs, including those taken for diabetes or to suppress the immune system. People with heart disease, schizophrenia, diabetes, or those with hormone-sensitive cancers, including breast, uterine, ovarian, or prostate cancer, should not take ginseng. There are many types of ginseng, and they are best prescribed by an experienced practitioner who can closely match the patient's needs. The wrong type of ginseng may be exacerbate your condition.
• Echinacea ( Echinacea species ) may help boost the immune system. However, studies have not looked at echinacea as a treatment for CFS. People with autoimmune disease, such as lupus or rheumatoid arthritis, should not take echinacea. Echinacea can interact with certain medications, including caffeine.

Essential oils of jasmine, peppermint, and rosemary may help reduce stress when used in aromatherapy. Place several drops in a warm bath or atomizer, or on a cotton ball.

Homeopathy

The appropriate homeopathic treatment for CFS depends on your constitutional type, includes your physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for each individual. Some remedies commonly used by professional homeopaths to treat CFS include:

• Arsenicum . For restlessness and fatigue accompanied by chills and burning pains that are worse at night.
• Gelsemium . For mental exhaustion, including drowsiness and indifference, and physical weakness, such as heaviness of the limbs and eyelids.
• Pulsatilla . For people who are moody and emotional, although usually with a calm and gentle disposition.
• Sulphur . For people who feel fatigue, but are usually not as emotionally sensitive as those requiring Pulsatilla .

Acupuncture

Several studies in China have indicated acupuncture may help treat CFS. Western studies have found that acupuncture may help conditions with similar symptoms, such as fibromyalgia, depression, headache, and irritable bowel syndrome.

Evidence also suggests that acupuncture may help boost your immune system. It may also help people with CFS get a more restful night's sleep, which is often key to turning the condition around.

Acupuncturists treat people with CFS based on an individualized assessment of the excesses and deficiencies of qi located in various meridians. In the case of CFS, a qi deficiency is usually detected in the spleen or kidney meridians, but a deficiency may also be found in the lung or liver meridians. CSF does not have to be caused by a deficient condition. It can also be a symptom of an excess in certain meridiens.

Acupuncturists may use moxibustion (a technique in which the herb mugwort is burned over specific acupuncture points) in addition to needling therapy, as it is thought moxibustion helps to provide a deeper and stronger treatment. Practitioners with herbal training may recommend specific herbal remedies, as well as dietary changes.

Chiropractic

Although no well-designed clinical trials have looked at chiropractic treatment for CFS, some chiropractors suggest that spinal manipulation may boost energy and reduce pain in some people with the condition.

Physical Therapies

Therapeutic massage can reduce stress-related symptoms, improve circulation, and increase your overall sense of well being. Physical exercise and exercise therapy have also been shown to improve symptoms.

Following Up

Your health care provider will do routine checkups while you are taking any drugs or following treatments for chronic fatigue syndrome. Contact your doctor if new symptoms develop.

Special Considerations

If you are pregnant, you should not use any herbs or supplements without your doctor's supervision. You should not take echinacea for long periods of time.

Supporting Research

Edmonds M, McGuire H, Price J. Exercise therapy for chronic fatigue syndrome. Cochrane Database Syst Rev .2004;(3):CD003200.

Ferri: Ferri's Clinical Advisor 2016 . 1st ed. Philadelphia, PA: Elsevier Mosby; 2015.

Grinde B. Is chronic fatigue syndrome caused by a rare brain infection of a common, normally benign virus? Med Hypotheses . 2008;71(2):270-4.

Hadlandsmyth K, Vowles KE. Does depression mediate the relation between fatigue severity and disability in chronic fatigue syndrome. J Psychosom Res . 2009;66(1):31-5.

Ho RT, Chan JS, Wang CW, et al. A randomized controlled trial of qigong exercise on fatigue symptoms, functioning, and telomerase activity in persons with chronic fatigue or chronic fatigue syndrome. Ann Behav Med . 2012;44(2):160-70.

Hobday RA, Thomas S, O'Donovan A, Murphy M, Pinching AJ. Dietary intervention in chronic fatigue syndrome. J Hum Nutr Diet . 2008;21(2):141-9.

Kempke S, Luyten P, Claes S, et al. Self-critical perfectionism and its relationship to fatigue and pain in the daily flow of life in patients with chronic fatigue syndrome. Psychol Med . 2013;43(5):995-1002.

Larun L, Brurberg KG, Odgaard-Jensen J, Price JR. Exercise therapy for chrnoic fatigue syndrome. Cochrane Database Syst Rev . 2015; 2:CD003200.

Ling JY, Shen L, Liu Q, Wang LY. Impacts on chronic fatigue syndrome of qi deficiency syndrome and T cell subgroups in patients treated with acupuncture at selective time. Zhongguo Zhen Jiu . 2013;33(12):1061-4.

Lorusso L, Mikhaylova SV, Capelli E, Ferrari D, Ngonga GK, Ricevuti G. Immunological aspects of chronic fatigue syndrome. Autoimmune Rev . 2009;8(4):287-91.

Lu C, Yang XJ, Hu J. Randomized controlled clinical trials of acupuncture and moxibustion treatment of chronic fatigue syndrome patients. Zhen Ci Yan Jiu . 2014;39(4):313-7.

Malouff JM, Thorsteinsson EB, Rooke SE, Bhullar N, Schutte NS. Efficacy of cognitive behavioral therapy for chronic fatigue syndrome: a meta-analysis. Clin Psychol Rev . 2008;28(5):736-45.

Neu D, Mairesse O, Montana X, et al. Dimensions of pure chronic fatigue: psychophysical, cognitive and biological correlates in the chronic fatigue syndrome. Eur J Appl Physiol . 2014;114(9):1841-51.

Rakel: Integrative Medicine . 2nd ed. Philadelphia, PA: Elsevier Saunders; 2007.

Tsai SY, Yang TY, Chen HJ, et al. Increased risk of chronic fatigue syndrome following herpes zoster: a population-based study. Eur J Clin Microbiol Infect Dis . 2014;33(9):1653-9.

van Heukelom RO, Prins JB, Smits MG, Bleijenberg G. Influence of melatonin on fatigue severity in patients with chronic fatigue syndrome and late melatonin secretion. Eur J Neurol . 2006;13:55-60.

Wang O, Xiong JX. Clinical observation on effect of electro-acupuncture on back-shu points in treating chronic fatigue syndrome. Zhongguo Zhong Xi Yi Jie He Za Zhi . 2005 Sep;25(9):834-6.

Williams G, Waterhouse J, Mugarza J, et al. Therapy of circadian rhythm disorders in chronic fatigue syndrome: no symptomatic improvement with melatonin or phototherapy. Eur J Clin Invest . 2002;32:831-7.

Yancey J, Thomas S. Chronic Fatigue Syndrom: Diagnosis and Treatment. American Family Physician . 2012;86(8)741-6.