What is the best treatment for long-term post-viral symptoms of myalgia (muscle pain) and malaise (general feeling of being unwell)?

Management of Long-Term Post-Viral Myalgia and Malaise

There is currently insufficient evidence to recommend any specific intervention for the management of long-term post-viral myalgia and malaise, though symptom-specific approaches may provide relief for some patients. 1

Understanding Post-Viral Myalgia and Malaise

• Post-viral myalgia and malaise often overlap with symptoms seen in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), particularly following COVID-19 infection 1
• These symptoms can significantly reduce quality of life and may persist for months or years after the initial infection 2
• Approximately 38% of patients hospitalized with COVID-19 experience musculoskeletal pain as a long-term post-COVID sequela 2

Recommended Approaches for Management

Pacing and Activity Management

• Pacing is recommended as a primary management strategy for patients with post-exertional malaise (PEM), which frequently accompanies post-viral myalgia and malaise 1, 3
• Exercise should be avoided in patients with PEM as it may worsen symptoms; studies show physical activity worsened symptoms in 75% of long COVID patients 1, 4
• Cognitive pacing should be considered alongside physical activity management for those experiencing cognitive dysfunction 1

Pharmacological Options

• Low-dose naltrexone has shown promise for neuroinflammation in ME/CFS and may help with post-viral myalgia 1
• H1 and H2 antihistamines (particularly famotidine) may alleviate symptoms in some patients but are not curative 1
• For pain management, consider:
  • Acetaminophen or NSAIDs for mild myalgia if no contraindications exist 1
  • Pregabalin, gabapentin, or amitriptyline may be tried for persistent myalgic pain 5

Supplements with Limited Evidence

• Coenzyme Q10 and D-ribose have shown some promise in treating fatigue in ME/CFS and may be worth considering 1
• These supplements may deserve further study but currently have limited evidence 1

Special Considerations

For Postural Orthostatic Tachycardia Syndrome (POTS)

• If POTS is present alongside myalgia and malaise, consider:
  • Pharmacological: β-blockers, pyridostigmine, fludrocortisone, or midodrine 1
  • Non-pharmacological: Increased salt and fluid intake, compression stockings 1

For Immune Dysfunction

• Intravenous immunoglobulin may be considered for immune dysfunction but should be implemented in consultation with an immunologist 1

Emerging Treatments Under Investigation

• Anticoagulant regimens have shown promise in addressing abnormal clotting in long COVID 1
• BC007 (a drug that neutralizes G protein-coupled receptor autoantibody levels) is being investigated 1
• Paxlovid has shown potential in both prevention and treatment of long COVID symptoms in early studies 1
• Probiotics may help alleviate both gastrointestinal and non-gastrointestinal symptoms 1

Important Cautions

• Graded exercise therapy and cognitive behavioral therapy remain controversial for management of ME/CFS and should be further investigated before recommending for post-viral conditions 1
• Avoid recommending exercise for patients with PEM as it may significantly worsen their condition 1, 4
• Be aware that 50% of individuals with pre-existing musculoskeletal pain experienced worsening of their symptoms after COVID-19 2

Monitoring and Follow-up

• Regular assessment of symptom severity and functional status is important 1
• Adjust management strategies based on response to interventions 1
• Consider referral to specialists (rheumatology, neurology) for severe or persistent symptoms 1