What is the treatment for chronic fatigue syndrome?

Treatment of Chronic Fatigue Syndrome

Cognitive-behavioral therapy (CBT) and graded exercise therapy are the first-line treatments for chronic fatigue syndrome, as these are the only interventions with proven efficacy for improving fatigue, functioning, and quality of life. 1, 2

Initial Management Framework

Establish Therapeutic Alliance and Diagnosis

• Build a collaborative patient-provider relationship while conducting thorough symptom evaluation and assessing for comorbid conditions 1
• Make a firm, positive diagnosis of CFS when symptoms persist for more than 6 months with significant functional impairment and no alternative physical or psychiatric disorder explains the presentation 1, 3
• Screen and treat contributing factors first: anemia (with iron or erythropoietin), hypothyroidism (thyroid replacement), depression, anxiety, and sleep disorders 4

Monitor Fatigue Systematically

• Use a 0-10 numeric rating scale at every clinical encounter, with scores ≥4 requiring comprehensive evaluation of physical, cognitive, and emotional domains 4
• Routinely assess fatigue severity, impact on daily activities, and coping strategies at each visit 1, 4

First-Line Non-Pharmacological Interventions

Cognitive-Behavioral Therapy (Strongly Recommended)

• Offer structured CBT delivered by trained professionals, focusing on thoughts, feelings, and behaviors related to fatigue 1, 2
• CBT demonstrates moderate improvements in fatigue, psychological distress, cognitive symptoms, and mental health functioning 1, 2
• Structure therapy to address catastrophic misinterpretations of symptoms and promote problem-solving of current life difficulties 5

Graded Exercise Therapy (Strongly Recommended)

• Start physical activity at low intensity and increase gradually based on individual tolerance 2, 4
• Prescribe moderate aerobic exercise (walking, swimming, cycling) 3-5 times weekly, tailored to functional status 4
• Promote a consistent pattern of activity, rest, and sleep as the foundation for gradual return to normal functioning 5
• Consider tai chi, qigong, or yoga as gentler alternatives, which show significant improvements in physical functioning, quality of life, pain, fatigue, and sleep quality 4

Mindfulness-Based Interventions

• Offer mindfulness-based programs, which show moderate effect sizes for enhancing quality of life 1, 4
• Discuss access to psychoeducational interventions periodically based on patient needs 1

Pharmacological Management

Pain Management Options (When Needed)

• Consider serotonin-norepinephrine reuptake inhibitors (SNRIs) for pain management and improved functional status 1, 4
• Offer pregabalin for pain management in patients with CFS 1, 2
• Bupropion may be considered for fatigue management based on favorable results in open-label trials, though evidence is limited 1, 4

Medications to AVOID

• Do NOT use stimulants for fatigue symptoms 6, 2
• Do NOT use opioids for pain related to CFS 1, 4
• Do NOT use NSAIDs for chronic pain related to CFS 1, 4
• Do NOT use corticosteroids, antivirals, or antibiotics as they show no benefit 1, 2
• Do not use mifepristone 1
• Do not use sedative-hypnotic drugs routinely due to FDA warnings 4
• Paroxetine and progestational steroids have not shown benefit 1

Important caveat: No pharmacologic therapies have robust evidence of efficacy for CFS itself; medications should only target specific symptoms like pain or comorbid conditions 2, 3, 7

Complementary Approaches

Acupuncture (Optional)

• Manual acupuncture can be considered with sessions of 20-30 minutes, three times weekly for 2-3 weeks, then twice weekly for 2 weeks, then weekly for 6 weeks 2, 4
• Adverse events are typically mild and infrequent 6

Multidisciplinary Team Approach

Core Team Members

• Primary care physicians lead management with referrals to appropriate specialists based on predominant symptoms 1, 2
• Mental health professionals implement evidence-based interventions like CBT and mindfulness-based therapies 1, 2
• Physical therapists and rehabilitation specialists address physical deconditioning and activity limitations 1
• Rheumatologists may be involved when CFS presents with significant musculoskeletal symptoms 1

Avoid Common Pitfalls

• Do not focus exclusively on either physical or psychological aspects—CFS requires addressing both biological and psychosocial factors 1
• Avoid the trap of endless diagnostic testing once CFS diagnosis is established 3
• Do not prescribe multiple medications without clear symptomatic targets 7

Ongoing Management and Follow-Up

• Reassess fatigue levels at every visit using the same 0-10 numeric scale to track treatment response 4
• Modify management strategies based on response and changes in clinical status 4
• Encourage long-term physical activity as a lifestyle change 1
• Refer to specialists for unresolved fatigue despite comprehensive management 4