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Treating the Most Disruptive Symptoms First

People with CFS display different patterns and severity of symptoms. Clinicians and patients should communicate with one another about which symptoms are most disruptive or disabling and tailor the management plan accordingly. Treatment can be directed toward the most problematic symptoms as prioritized by the patient, but only after underlying conditions applicable to those symptoms have been investigated and excluded.

Fatigue Due to Sleep Problems

Most CFS patients have some form of sleep dysfunction. Common sleep complaints include difficulty falling asleep, hypersomnia (extreme sleepiness), frequent awakening, intense and vivid dreaming, restless legs, and nocturnal myoclonus (night-time muscular spasm). Most CFS patients report that they feel less refreshed and restored after sleep than they felt before they became ill.

Doctors can help people with CFS adopt good sleep habits. Patients should be advised to practice standard sleep hygiene techniques:

  • Establish a regular bedtime routine
  • Avoid napping during the day
  • Incorporate an extended wind-down period
  • Use the bed only for sleep and sex
  • Schedule regular sleep and wake times
  • Control noise, light, and temperature
  • Avoid caffeine, alcohol, and tobacco
  • Try light exercise and stretching earlier in the day, at least four hours before bedtime, because this may also improve sleep

When patients try these techniques but are still unable to sleep, the doctor may recommend taking medicine to help with sleep. Initial medications to consider are simple antihistamines or over-the-counter sleep products. If this is not beneficial, health care professionals are encouraged to start with a prescription sleep medicine in the smallest possible dose and briefest period possible.

Unrefreshing sleep can be present even though medications may help patients achieve required hours of sleep. A sleep specialist should evaluate patients whose sleep remains non-restorative following standard interventions.

Primary sleep disorders such as sleep apnea (brief pause in breathing during sleep) and narcolepsy (uncontrollable sleeping) exclude the diagnosis of CFS, and most people with such disorders respond to therapy. It is very important for health care professionals to get a careful sleep history and recommend a sleep study, if indicated.


People with CFS often experience deep pain in their muscles and joints. Patients may also complain of headaches (typically pressure-like) and soreness of their skin when touched.

Most doctors begin by recommending the patient take pain-relievers like acetaminophen, aspirin, ibuprofen, or acetaminophen. Additional pain therapy, if needed, can be managed by a pain specialist. Counseling for pain management techniques is advisable for CFS patients who experience constant pain.

Pain management should also include stretching and movement therapies, gentle massage, heat, toning exercises, hydrotherapy (water therapy for healing), and relaxation techniques. Acupuncture, when administered by a qualified practitioner who is knowledgeable about CFS, may be effective in relieving pain for some patients.

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Memory and Concentration Problems

Memory and concentration complaints are two of the more distressing symptoms reported by people with CFS. Relaxation and meditation training and memory aids, such as organizers, schedulers, and written resource manuals, can be helpful in addressing cognitive problems. Stimulating the mind with puzzles, word games, card games and other activities may also be beneficial for some patients.

Health care professionals should use caution in prescribing stimulants for cognitive problems. Mild stimulants may be helpful for some patients, but stronger stimulants can lead to the push-crash cycle (do too much, crash, rest, start to feel a little better, do too much once again, and so on) and cause relapse.

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Depression and Anxiety

Adjusting to a chronic, debilitating illness can sometimes lead to depression. As many as half of CFS patients develop depression at some time during the course of their illness. When it's present, depression needs to be treated. Although treating depression can reduce anxiety and stress, it is not a cure for CFS.

Doctors are advised to use caution in prescribing antidepressants. Antidepressant drugs of various classes have other effects that might worsen other CFS symptoms and cause side effects. There are brief psychiatric screening tools available that can be given and scored in the primary care setting, such as the Beck Depression Inventory. Results of these screening tools that point to a possible underlying depression or other psychological disorder may warrant a referral to a mental health professional.

In addition, deep breathing and muscle relaxation techniques, massage and healing touch, and movement therapies like stretching, yoga and tai chi can be beneficial for some CFS patients in reducing anxiety and promoting a sense of well-being.

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Dizziness and Lightheadedness (Orthostatic Instability)

Some patients with CFS may also exhibit symptoms of orthostatic instability, in which symptoms are triggered or made worse by standing upright, in particular frequent dizziness and light-headedness. When clinicians judge these symptoms to be severe enough to warrant additional assessment, they should refer patients for evaluation by a cardiologist or neurologist. Specific treatment for orthostatic instability should only be started following confirmed diagnosis and by clinicians experienced in evaluating therapeutic results and managing possible complications.

Treatments for orthostatic problems include volume expansion for CFS patients who do not have heart or blood vessel disease. If symptoms do not improve with increased fluid and salt intake, prescription medications and support stockings can be prescribed.

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