How to manage chronic fatigue, dizziness, and headaches in patients with Myalgic Encephalomyelitis (ME)?

Management of Chronic Fatigue, Dizziness, and Headaches in Myalgic Encephalomyelitis

Prioritize cognitive-behavioral therapy (CBT) and paced activity management as first-line interventions for ME/CFS, while avoiding pharmacological agents that lack evidence for fatigue reduction, and address dizziness through orthostatic intolerance management and headaches through standard migraine protocols when appropriate. 1, 2

Initial Assessment and Symptom Characterization

Confirm the diagnosis requires profound fatigue lasting ≥6 months with substantial reduction in pre-illness activities, accompanied by postexertional malaise, unrefreshing sleep, and either cognitive impairment or orthostatic intolerance. 1 The presence of dizziness in ME/CFS often represents orthostatic intolerance, which is a core diagnostic feature. 1

• Systematically rule out treatable conditions causing chronic fatigue including anemia, hypothyroidism, depression and anxiety disorders, sleep disorders, electrolyte disturbances, and chronic infections before attributing symptoms solely to ME/CFS. 1
• Conduct psychosocial assessment including psychological trauma history and obtain complete medical history. 3
• Screen fatigue severity using a 0-10 numeric rating scale at every clinical encounter, with scores ≥4 requiring comprehensive evaluation including assessment of physical, cognitive, and emotional domains. 1

First-Line Non-Pharmacological Management

Cognitive-Behavioral Therapy

Offer structured CBT as the primary intervention, which demonstrates the strongest evidence for improving health function, quality of life, and physical functioning in ME/CFS. 1, 2, 4 CBT should be tailored to address thoughts, feelings, and behaviors related to fatigue. 2

Activity Pacing and Energy Management

Promote a consistent pattern of activity, rest, and sleep, starting physical activity at low intensity and gradually increasing based on tolerance. 1 This is the most important coping strategy patients can learn to manage post-exertional fatigue and malaise. 5

• Avoid pushing through fatigue, as this worsens postexertional malaise, a hallmark feature of ME/CFS. 1, 5
• Strategic rest periods between activities prevent symptom exacerbation and allow patients to regain ability to plan activities. 5

Mind-Body Interventions

Consider mindfulness-based interventions such as mindfulness-based stress reduction and mindfulness-based cognitive therapy for enhancing quality of life. 1, 2 These show moderate effect sizes compared to waitlist or support group controls. 2

Physical Activity Interventions

Introduce physical exercise gradually, as it has shown statistical benefits in improving quality of life and reducing pain, but must be carefully titrated to avoid postexertional malaise. 2, 3

• Offer yoga or tai chi, which demonstrate significant improvements in physical functioning, quality of life, pain, fatigue, sleep quality, and mood. 3, 2 Longer duration of treatment shows greater improvement. 3
• Moderate-intensity resistance training and aerobic exercise can improve strength, energy, and fitness when tolerated. 2

Critical caveat: Exercise must be approached cautiously in ME/CFS, as inappropriate exercise prescription can worsen symptoms through postexertional malaise. 1, 5

Pharmacological Management: What NOT to Use

Avoid stimulants, corticosteroids, antivirals, or antibiotics for ME/CFS, as they have no demonstrated benefit. 1, 2, 4 The VA/DoD guideline explicitly states there has been no new evidence since 2014 to suggest any benefit for steroids, antivirals, or antibiotics. 3

• Avoid NSAIDs for chronic pain related to ME/CFS. 3, 2
• There is insufficient evidence to recommend for or against duloxetine specifically for ME/CFS. 4 The guideline makes no recommendation in favor of any pharmacologic agent for the management of ME/CFS. 4

Pharmacological Management: Limited Options for Specific Symptoms

For Pain Management (if significant)

Consider serotonin-norepinephrine reuptake inhibitors (SNRIs) or pregabalin for pain management and improved functional status, though evidence is insufficient specifically for ME/CFS fatigue. 1, 2

• SNRIs may be appropriate for patients with concurrent fibromyalgia with significant pain as a predominant symptom, or for those with comorbid depression or anxiety. 4
• Pregabalin may be offered for pain management. 3, 2
• Warning: Prescribing SNRIs for ME/CFS without a clear indication may expose patients to side effects such as nausea, constipation, and sexual dysfunction without benefit. 4

For Fatigue (limited evidence)

Bupropion may be considered for fatigue management based on favorable results in open-label trials, though evidence is limited. 2

• Modafinil may be effective for individuals with severe fatigue, though overall trial results were negative, and should be used with caution. 2
• Paroxetine has not shown benefit for ME/CFS and should not be used. 2

Management of Dizziness (Orthostatic Intolerance)

Address orthostatic intolerance, which is a core diagnostic feature of ME/CFS and commonly manifests as dizziness. 1

• Increase fluid and salt intake to expand blood volume. [General Medicine Knowledge]
• Consider compression stockings to reduce venous pooling. [General Medicine Knowledge]
• Educate patients on positional changes (rising slowly from sitting/lying positions). [General Medicine Knowledge]
• If severe, consider referral to cardiology or autonomic specialist for further evaluation and potential pharmacological management. [General Medicine Knowledge]

Management of Headaches

Treat headaches according to standard migraine protocols when appropriate, recognizing that headache is a common symptom in chronic multisymptom illness. 3

• For chronic migraine patterns, consider topiramate or amitriptyline as preventive therapy. 3
• Limit acute medication use to prevent medication overuse headache: simple analgesics to fewer than 15 days/month and triptans to fewer than 10 days/month. 3
• Offer cognitive-behavioral therapy and biofeedback for headache management. 3
• Avoid beta-blockers if they may exacerbate fatigue or depression. 3

Complementary Approaches

Consider manual acupuncture as part of management, with evidence supporting its effectiveness. 3, 2

• Emotion-focused therapy should be considered as it has shown benefits for patients with chronic multisymptom illness. 3, 2
• There is insufficient evidence to recommend for or against manual musculoskeletal therapies. 3

Monitoring and Follow-Up

Reassess fatigue levels at every visit using the same 0-10 numeric scale to track response, and modify management strategies based on response and changes in clinical status. 1

• Regularly assess fatigue severity, impact, and coping strategies in clinical consultations. 2
• Decisions on managing fatigue should be shared between the patient and healthcare providers. 2
• Access to psychoeducational interventions should be discussed periodically based on patient needs. 2

Multidisciplinary Referrals

Consider referral to mental health professionals, physical therapists, rheumatologists, sleep specialists, and integrative medicine specialists for comprehensive management of ME/CFS. 1

• Establish an interprofessional care team based on patient needs. 3
• Building and maintaining a therapeutic patient-provider alliance is crucial. 2

Common Pitfalls to Avoid

• Do not dismiss symptoms as purely psychological—ME/CFS is a complex medical condition with immune dysregulation and mitochondrial dysfunction. 6
• Do not prescribe graded exercise therapy without careful consideration of postexertional malaise—inappropriate exercise can worsen symptoms. 1, 5
• Do not use pharmacological agents without clear indication—most medications lack evidence for ME/CFS-specific fatigue and expose patients to unnecessary side effects. 4
• Do not order extensive diagnostic testing beyond ruling out alternative diagnoses—avoid tests with limited additional benefit. 3