How to manage chronic extensive fatigue, brain fog, and dizziness?

Management of Chronic Extensive Fatigue, Brain Fog, and Dizziness

Begin with a systematic evaluation of treatable contributing factors including sleep disorders, medication effects (particularly beta-blockers), depression, nutritional deficiencies, and deconditioning, followed by implementation of cognitive behavioral therapy and graded physical activity as first-line interventions. 1, 2

Initial Assessment and Diagnostic Workup

Essential Laboratory Testing

• Obtain a comprehensive metabolic panel to identify electrolyte imbalances (sodium, potassium, calcium, magnesium) that commonly cause fatigue 2
• Check complete blood count with differential to exclude anemia and hematologic abnormalities 3
• Measure thyroid function tests (TSH, free T4) as thyroid dysfunction frequently presents with fatigue and cognitive symptoms 3
• Assess inflammatory markers (ESR, CRP) to evaluate for underlying inflammatory processes 3
• Screen for nutritional deficiencies including iron, vitamin B12, and vitamin D that contribute to fatigue 4

Critical Clinical Evaluation

• Conduct a detailed medication review, as beta-blockers (like metoprolol), antidepressants, and other CNS-active medications are common culprits of fatigue 2, 1
• Assess for orthostatic intolerance by performing a 3-minute active stand test (or 10 minutes if postural tachycardia syndrome is suspected) to evaluate for autonomic dysfunction contributing to dizziness 1, 4
• Screen for depression using validated tools such as the PHQ-9, as depression accounts for a significant proportion of chronic fatigue cases 2
• Evaluate sleep quality comprehensively, including sleep onset, maintenance, sleep hygiene practices, and evening alcohol consumption (which disrupts sleep architecture) 2, 1

First-Line Treatment Interventions

Cognitive Behavioral Therapy (CBT)

Cognitive behavioral therapy specifically tailored for chronic fatigue should be offered as initial treatment, focusing on addressing catastrophic misinterpretations of symptoms, establishing consistent activity-rest patterns, and problem-solving current life difficulties. 1, 5, 6

• CBT for chronic fatigue targets illness-perpetuating factors including inconsistent activity patterns, fear of symptom worsening, and maladaptive coping strategies 5
• Treatment can be delivered through in-person individual or group sessions, telephone-based modules, or web-based programs 1
• The therapy should address the distinction between predisposing factors (lifestyle, work stress), triggering factors (viral infections, life events), and perpetuating factors (sleep disorder, depression, deconditioning, fear of activity) 5

Graded Physical Activity

Implement a structured, gradual return to physical activity starting with low-level activities (10-15 minute walks) and slowly increasing intensity and duration over weeks to months. 1, 2

• Begin with supervised physical activity interventions that consider current sedentary behavior, disease activity, comorbidities, and patient preferences 1
• Avoid "boom and bust" activity patterns where patients overexert on good days and crash afterward 1
• Energy conservation strategies should be taught, including prioritizing activities, pacing, and delegating non-essential tasks 1
• Maintain a daily activity diary to identify peak energy periods and plan activities accordingly 1

Sleep Optimization

Address sleep disturbances as a priority, as poor sleep quality is a major perpetuating factor for fatigue and cognitive symptoms. 1, 2

• Establish consistent sleep-wake times, even on weekends 1
• Remove incompatible activities from the bedroom including television, computer use, eating, and "clock watching" 1
• Reduce or eliminate evening alcohol consumption, as it significantly disrupts sleep architecture despite initial sedating effects 2
• Consider cognitive behavioral therapy for insomnia (CBT-I) as the gold standard treatment if insomnia persists 1

Medication Management

Review and Optimize Current Medications

• If taking beta-blockers, discuss with the prescribing physician whether the medication can be changed to an alternative class or the dose reduced, as these commonly cause fatigue 2
• Review all medications including over-the-counter products, herbal remedies, and dietary supplements for potential interactions contributing to fatigue 7
• Avoid polypharmacy, as combinations of CNS-active medications can have cumulative effects on fatigue and cognitive function 7

Pharmacologic Considerations

• Antidepressants may be tried on a pragmatic basis if depression is present, but their role in treating fatigue without depression remains uncertain 5, 8
• Avoid prescribing stimulants or wakefulness-promoting agents (like modafinil) as first-line treatment, as these do not address underlying perpetuating factors and are indicated only for specific sleep disorders like narcolepsy 9
• Other medications should generally be avoided unless treating specific comorbid conditions 5

Management of Dizziness

Autonomic Dysfunction Assessment

• If orthostatic intolerance is confirmed by active stand testing, implement non-pharmacologic interventions first 1, 4
• Increase fluid intake to 2-3 liters daily and salt intake (unless contraindicated by hypertension or heart failure) 4
• Use compression stockings to reduce venous pooling 4
• Teach counter-maneuvers such as leg crossing and muscle tensing before standing 4

Follow-Up and Monitoring Strategy

Schedule follow-up within 2-4 weeks after implementing initial interventions to assess response and adjust treatment. 2

• Use a standardized fatigue scale (such as the Fatigue and Altered Cognition Scale) to objectively track progress over time 10, 2
• Reassess regularly and modify treatment based on response, recognizing that improvement may take 6-8 weeks or longer 7, 2
• If fatigue remains unresolved after 3 months despite appropriate interventions, consider referral to specialists including neurology, rheumatology, or chronic fatigue clinics 2

Common Pitfalls to Avoid

• Do not order extensive diagnostic testing beyond the essential workup, as this reinforces illness beliefs and rarely yields actionable findings 5, 8
• Avoid attributing all symptoms to psychological causes without first addressing medical contributors like sleep disorders, medications, and nutritional deficiencies 2, 4
• Do not recommend complete rest or activity avoidance, as deconditioning paradoxically worsens fatigue 1, 5
• Avoid prescribing multiple medications simultaneously without addressing behavioral and lifestyle factors first 5, 8
• Do not dismiss patient concerns or suggest symptoms are "not real"—validate the disability while emphasizing that rehabilitation does not imply the illness is imaginary 6