Treatment of Chronic Fatigue Syndrome
Cognitive-behavioral therapy (CBT) and graded exercise therapy are the first-line treatments for chronic fatigue syndrome, with the strongest evidence for improving health function, quality of life, and physical functioning. 1, 2, 3
Initial Management Approach
Begin with structured cognitive-behavioral therapy administered by trained professionals, focusing specifically on thoughts, feelings, and behaviors related to fatigue. 1, 2 CBT demonstrates moderate improvements in fatigue, psychological distress, cognitive symptoms, and mental health functioning across multiple trials. 1, 2
Simultaneously introduce graded exercise therapy, starting at low intensity with moderate aerobic exercises (walking, swimming, cycling) 3-5 times per week, gradually increasing based on tolerance while carefully avoiding postexertional malaise. 2, 3 This approach shows statistical benefits in improving quality of life and reducing pain. 1, 2
Complementary Non-Pharmacological Options
Mindfulness-based interventions (mindfulness-based stress reduction or cognitive therapy) show moderate effect sizes for enhancing quality of life compared to waitlist controls. 1, 3
Yoga or tai chi demonstrate significant improvements in physical functioning, quality of life, pain, fatigue, sleep quality, and mood, with longer treatment duration showing greater benefit. 1, 3
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. 1, 2
Emotion-focused therapy has shown benefits and should be considered as part of the treatment plan. 1, 3
Pharmacological Management
Medications to Consider
For pain management and functional improvement, serotonin-norepinephrine reuptake inhibitors (SNRIs) can be offered, though evidence is insufficient specifically for CFS fatigue. 1, 2, 3
Pregabalin may be offered 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 remains limited. 1, 2, 3
Medications to AVOID
Do NOT prescribe the following medications, as they have no demonstrated benefit or potential harm:
- Stimulants - explicitly recommended against by multiple guidelines 4, 1, 2, 3
- Opioids - no benefit for CFS-related pain 1, 2
- NSAIDs - ineffective for chronic pain in CFS 1, 2
- Corticosteroids - no demonstrated benefit 1, 2, 3
- Antivirals - no benefit 1, 2, 3
- Antibiotics - no benefit 1, 2, 3
- Immunoglobulin therapy (IVIG) - no demonstrated benefit 1
- Paroxetine - has not shown benefit 1
- Progestational steroids - no demonstrated benefit 1
Symptom-Specific Management
For orthostatic intolerance and dizziness (a core diagnostic feature), increase fluid and salt intake, consider compression stockings, and educate patients on gradual positional changes. 3
For headaches, treat according to standard migraine protocols when appropriate, recognizing headache as a common symptom in chronic multisymptom illness. 3
Monitoring and Follow-Up
Reassess fatigue levels at every visit using a 0-10 numeric scale to track treatment response consistently. 2, 3
Regularly assess fatigue severity, impact, and coping strategies during clinical consultations, modifying management strategies based on response and changes in clinical status. 1, 2, 3
Promote a consistent pattern of activity, rest, and sleep as an ongoing lifestyle intervention throughout treatment. 2, 3
Multidisciplinary Team Involvement
Primary care physicians should lead management with referrals to appropriate specialists based on predominant symptoms. 1, 2
Mental health professionals are crucial for implementing evidence-based interventions such as CBT and mindfulness-based therapies. 1, 2
Physical therapists and rehabilitation specialists address physical deconditioning and activity limitations. 1, 2
Consider referrals to rheumatologists when CFS presents with significant musculoskeletal symptoms. 1
Critical Pitfalls to Avoid
Do not attribute symptoms solely to CFS before systematically ruling out treatable conditions including anemia, hypothyroidism, depression, and anxiety disorders. 3
Avoid exclusive focus on either physical or psychological aspects - CFS requires addressing both biological and psychosocial factors simultaneously. 1
Do not prescribe pharmacotherapy as first-line treatment - it should always be used in the context of self-management and rehabilitation strategies. 5