Chronic Fatigue SyndromeSkip to the navigation
What is chronic fatigue syndrome (CFS)?
Chronic fatigue syndrome (CFS), sometimes called myalgic encephalomyelitis (ME), is a condition that makes you feel so tired that you can't do all of your normal, daily activities. There are other symptoms too, but being very tired is the main one. Some people have severe fatigue and other symptoms for many years.
CFS is not well understood. Most experts now believe that it is a separate illness with its own set of symptoms. But some doctors don't believe this.
There are no tests for CFS. Because of this, many people have trouble accepting their disease or getting their friends and family to do so. Having people who believe your diagnosis and support you is very important. Having a doctor you can trust is critical.
Your tiredness is real. It's not "in your head." It is your body's reaction to a mix of factors.
What causes CFS?
Doctors don't know what causes CFS. Sometimes it begins after a viral infection, but there is no proof of any connection. It's likely that a number of factors or triggers come together to cause CFS.
What are the symptoms?
Extreme tiredness, or fatigue, is the main symptom. If you have CFS:
- You may feel exhausted all or much of the time.
- You may have problems sleeping. Or you may wake up feeling tired or not rested.
- It may be harder for you to think clearly, to concentrate, and to remember things.
- You may also have headaches, muscle and joint pain, a sore throat, and tender glands in your neck or armpits.
- Your symptoms may flare up after a mental or physical activity that used to be no problem for you. You may feel drained or exhausted.
Depression is common with CFS, and it can make your other symptoms worse.
How is CFS diagnosed?
There are no tests for CFS. Doctors can diagnose it by ruling out other possible causes of your fatigue and by using a set of rules. Many other health problems can cause fatigue. Most people with fatigue have something other than chronic fatigue syndrome.
Here is one set of criteria (rules) that doctors use to diagnose chronic fatigue syndrome:footnote 1
- The fatigue and the other symptoms must last, or come and go, for at least 6 months in adults or 3 months in children.
- The symptoms cannot be explained by another illness.
- All of these symptoms must be present:
- Extreme physical or mental fatigue
- Not feeling well after being active (post-exertional malaise)
- Sleep problems
- Two or more of these symptoms related to brain function must be present:
- Problems with concentration, short-term memory, or thinking of the right word
- Being very sensitive to light, noise, or emotions
- Confusion, slow thinking, or feeling disoriented
- Muscle weakness or muscle coordination problems
- One or more symptoms from two of these groups must be present:
- Recurrent flu-like symptoms, sore throats, tender lymph nodes, or new sensitivities to food, medicines, odors, or chemicals
- Low body temperature, cold hands and feet, sweating, or feeling worse when under stress
- Lightheadedness and dizziness, very fast heartbeat, or shortness of breath when active
How is it treated?
There is no treatment for CFS itself, but many of its symptoms can be treated. A good relationship with your doctor is important. That's because the two of you will need to work together to find a combination of medicines and behavior changes that will help you get better. Some trial and error may be needed, because no single combination of treatments works for everyone.
Home treatment is very important. You may need to change your daily schedule, learn better sleep habits, and use regular gentle movement or exercise to fight fatigue. Even at times when you have more energy, keep a low-key pace throughout each day. Rest often.
Living with CFS can be as much a mental health challenge as it is a physical one. Take steps to avoid getting caught in a cycle of frustration, anger, and depression. Learning to cope with your symptoms and talking to others who have CFS can help. So can working with a counselor.
Frequently Asked Questions
Learning about chronic fatigue syndrome (CFS):
Living with chronic fatigue syndrome (CFS):
Health Tools help you make wise health decisions or take action to improve your health.
Doctors don't know what causes chronic fatigue syndrome (CFS). For many people, CFS symptoms start after a viral illness. In some cases, CFS seems to follow a major physical or emotional trauma or an exposure to toxins. But there is no single known cause of CFS.
Other theories point to the immune system, glands and hormones, and family history. But again, there's not enough evidence to prove a solid connection.
Chronic fatigue syndrome (CFS) symptoms usually start suddenly. But for some people, they develop gradually over weeks or months. Symptoms can change in a day, and from day to day. They tend to stop (remission) and then start again (relapse).
There is broad range of CFS symptoms. But there is a core set of symptoms that affect nearly everyone with CFS. These core symptoms are:
- Extreme physical fatigue, mental fatigue, or both. It can be constant, or it can come and go. It is not relieved by rest. This fatigue also is so severe that it interferes with your work, your play, and your social activities.
- Feeling unwell after being active. This can mean you feel ill or weak or your CFS symptoms are worse. There can be a delay before it starts. It can take more than 24 hours to feel better.
- Sleep problems.
- Pain, which can be widespread or in one place. CFS pain can be in one area, then move to another. You may have:
- Muscle pain.
- Joint pain.
A person with CFS also has two or more of these symptoms:
- Problems with concentration, short-term memory, or thinking of the right word
- Being very sensitive to light, noise, or emotions
- Confusion, slow thinking, or feeling disoriented
- Muscle weakness or muscle coordination problems
CFS also causes the following symptoms. Different people with CFS have different combinations of:
- Lightheadedness and dizziness, very fast heartbeat, or shortness of breath when active.
- Urinating often, nausea, or irritable bowel syndrome (IBS).
- Low body temperature, cold hands and feet, sweating, or trouble with heat or cold.
- Feeling worse when under stress.
- Weight change or appetite change.
Having depression along with CFS is common and can make CFS symptoms worse.
CFS causes symptoms that are the same as many other diseases, especially early on. For this reason, it can be diagnosed only after a thorough evaluation has ruled out other conditions with similar symptoms.
In some cases, chronic fatigue syndrome (CFS) develops after a flu-like illness such as mononucleosis (mono) or after a period of unusual stress. But it may also occur without warning, even if you have not been sick.
The fatigue may come upon you gradually or quite suddenly. Because fatigue can be vague and can be caused by many things, you might not pay attention to the problem for several weeks or months. It is hard to say what is normal with CFS. That's because the diagnosis often is not clear for some time.
- Symptoms are worse at the beginning.
- You may feel better for a time and then feel worse again. Some people have severe fatigue and other symptoms for many years. But many people will feel somewhat better or a lot better over time.
Some people find the fatigue, pain, and thinking problems caused by CFS greatly hamper their lives. But other people are not nearly as affected.
- Most people are still able to do some of their usual activities at home and work, but they often are unusually tired after they do them. People often have to cut down on social and recreational activities to save their energy for work and family.
- Other people have trouble doing most or all of their daily activities, including work and the basic chores of daily living. They may have to carefully plan how to best use their energy.
- People with severe CFS have trouble getting out of bed and need help with basic activities such as dressing, eating, and bathing.
What Increases Your Risk
People who have chronic fatigue syndrome (CFS) are generally 25 to 45 years of age. Women are more likely to have CFS.
CFS is rare in children. It may occur in teens, especially young teenage girls. Unlike adults, teens are more likely to develop CFS after having a flu-like illness.
When To Call a Doctor
It's important to talk to your doctor about any symptoms you may have.
Call your doctor if you have:
- Severe fatigue that lasts longer than 2 weeks, causes you to limit your usual activities, and does not improve with rest.
- Sleep problems that last for more than 1 to 2 months. These problems may include being unable to fall asleep or stay asleep, tossing and turning, and waking up feeling tired or not rested.
- Swelling in the glands in your neck or armpits (without other signs of infection) that lasts for at least 2 weeks.
- Severe fatigue along with frequent urination (especially at night), extreme thirst, weight loss, or blurred vision. Fatigue that occurs with some or all of these may be a symptom of undiagnosed diabetes.
- Headache that lasts longer than 2 weeks.
Watchful waiting refers to a period of time in which you are being watched by your doctor but are not getting treatment. A month or two of paying close attention to your sleep habits, getting regular moderate exercise, trying to control stress, and eating a balanced diet will take care of most cases of fatigue not caused by CFS or another medical problem. But if your fatigue has not improved after 1 to 2 months of self-care, or if fatigue won't go away and limits your usual activities, call your doctor.
If you have been diagnosed with CFS, pay attention to any new symptoms and report them to your doctor. Although CFS can cause a variety of symptoms, new symptoms could be caused by another illness or medical condition that may need to be evaluated and treated.
Who to see
The following health professionals can evaluate fatigue and other symptoms:
There are doctors who specialize in the treatment of CFS. Get a recommendation from your family doctor or a local CFS support group before you make an appointment with a specialist. It is always wise to start with your family doctor. You may also be referred to a physiatrist, psychologist, or psychiatrist.
To prepare for your appointment, see the topic Making the Most of Your Appointment.
Exams and Tests
Chronic fatigue syndrome (CFS) is hard to diagnose. It is common to have normal test results when you have CFS. Fatigue is an extremely common problem, and it can have many other causes. CFS can be diagnosed only by ruling out other conditions.
First, your doctor will ask you about past health and do a physical exam. Experts have come up with a specific list of symptoms to decide whether a person has CFS. Doctors use a variety of tests to rule out other conditions. These tests usually include:
- Complete blood count (CBC). This gives important information about the kinds and numbers of cells in your blood.
- Erythrocyte sedimentation rate (ESR). This test measures how quickly red blood cells (erythrocytes) settle in a test tube. This tells whether or not certain types of inflammation are present.
- Blood glucose level, used to check for diabetes.
- Thyroid-stimulating hormone test. It's used to find problems that affect the thyroid gland.
- Chemistry panel. This is a blood test that provides information about your general state of health.
- Urinalysis, a urine test that can provide information about your overall health and clues to many conditions.
These are routine lab tests. Other tests may be done if your symptoms, history, and physical exam suggest other possible problems. These other tests may include:
- ANA (antinuclear antibodies), to check for lupus (systemic lupus erythematosus).
- Rheumatoid factor, to check for rheumatoid arthritis.
- HIV test, to check for human immunodeficiency virus (HIV) infection.
- Tests for Lyme disease, if you may have been exposed to ticks.
- Skin test, for tuberculosis.
- Hepatitis A, hepatitis B, or hepatitis C tests.
Some doctors may order tests that check your immune system. These can be expensive and generally are done only in research settings. Also, it's hard to know what the findings of these tests mean. That's because so little is known about the immune system's connection to chronic fatigue syndrome.
Since there is not yet a cure for chronic fatigue syndrome (CFS), the key to living with CFS is treating your symptoms.
- Find a primary doctor who understands CFS and how to treat it, and who helps you feel supported.
- Track what helps you feel better, as well as the things that make your symptoms worse.
- Use a mix of medical care, daily self-care, and support.
- For regular support you can count on, work with a professional counselor, a CFS support group, or both.
- Get specialist care when you need it. Sign "release of information" forms so that your doctors can work together as a team.
Treat the worst first
Start by listing your worst symptoms—the ones that make it hardest to get through the day. With your doctor, focus first on treating those symptoms. Decide whether a specialist might be helpful for any of them.
The most common CFS symptoms can also be the most treatable.
Good sleep habits can help improve the quality of your sleep. If you also try medicine for sleep, it's best to start on a low dose. Certain antidepressants help with sleep, mood, and chronic pain, so your doctor may suggest trying one.
Different kinds of pain can be treated in different ways. If one treatment doesn't work, you and your doctor can try another until you find what works best for you.
- It's important to control focused pain, such as arthritis or migraine, because this kind of pain can make CFS body pain worse. First try an over-the-counter pain reliever, like acetaminophen (such as Tylenol), ibuprofen (such as Advil or Motrin), or naproxen (such as Aleve). Be safe with medicines. Read and follow all instructions on the label.
- There are different types of prescription medicines that help with pain, such as antidepressants for chronic pain and narcotic medicine for severe pain. A narcotic is a short-term treatment because it can become addictive if you use it a lot.
- Other treatments that can help with CFS pain include acupuncture, massage, or yoga.
Do all you can to take charge of your fatigue level. Even when you have more energy, keep a low-key pace throughout each day.
- Adjust your daily schedule to take advantage of times when you have more energy. Take rest breaks often.
- Unless your CFS is severe, try a graded exercise program, starting out with gentle and easy movement. Start with as little as 1 minute, and slowly add more over days or weeks. Studies have shown that a carefully planned graded exercise program can help some people with CFS regain their strength and energy and feel better.footnote 2
- Try cognitive-behavioral therapy (CBT). This is a type of counseling that has been shown to help some people who have CFS feel less tired.footnote 2 It teaches you how to change the way you think and do things. These changes can help you better cope with fatigue and other symptoms.
Depression, anxiety, and distress
Living with CFS can be as much a mental health challenge as it is a physical one. It's easy to get caught in a cycle of frustration, anger, and depression.
- Work with your doctor to watch for signs of depression. It can be easy to mistake depression for CFS fatigue.
- If your doctor suggests an antidepressant, ask if there is one that may not only improve your mood, but also help control your pain and help you sleep.
- For support and help with mood problems, you can also work with a professional counselor who understands CFS.
Get specialist care when you need it
You can expect your symptoms to come and go. For some people, certain things trigger long periods of worse symptoms. Visit your doctor every few months to help track your symptoms and check for any need to change your treatment.
Get specialized care if you need it. For example:
- A rehabilitation specialist can help you start a graded exercise plan. He or she can also treat pain.
- A pain management specialist can offer a number of pain treatments.
- There are some specialists who work with experimental treatments such as antiviral medicines.
What to think about
There are many unproven remedies, such as special diets or mineral supplements, that some people recommend for treating CFS. There is no evidence that any of these are effective.footnote 2
Your mind and body are connected and affect each other. Physical illnesses can be made worse—or better—by your feelings and attitudes, and vice versa. Learn as much as you can about CFS. Then work with your doctor to learn ways to cope with your symptoms. Get emotional support from your health professionals as well as from your family and friends.
Chronic fatigue syndrome (CFS) can't be prevented or cured. But treatment can help control or reduce symptoms.
Home treatment is the most important part of treating chronic fatigue syndrome (CFS). You can take steps to control and sometimes relieve your CFS symptoms:
- Adjust your schedule to take advantage of times when you have more energy and feel less tired. Keep a diary for a week or so. Write down the times of day when you have energy and when you are tired. If there is a pattern to how your energy level changes during the day, try to plan your work, school, or other activities around that pattern.
- Do what you can to take charge of your fatigue level. Try not to do too much when you have more energy. If you do too much, you may become overtired. And it may take several days for you to recover.
- Improve your sleep habits. Sleep problems may
add to your fatigue and other symptoms.
- Go to bed only when you are sleepy. Get up at the same time every day, whether or not you feel rested.
- If you lie awake for longer than 15 minutes, get up, leave the bedroom, and do something quiet until you feel sleepy again.
- Avoid alcohol, caffeine, and tobacco well before bed. Alcohol can disrupt your sleep when you drink it within 4 hours of bedtime. Caffeine is a stimulant that stays in the body for 12 hours. So make sure to avoid it during that block of hours before your bedtime.
- Keep the bedroom at a comfortable temperature. Get rid of all sound and light disturbances.
- Make sure your mattress provides good support. Use a neck support pillow to keep your head and neck from moving too much when you sleep.
- Take naps if you need to. Keep them short (20 to 60 minutes). And try not to take them late in the day or evening.
- Get light, gentle exercise regularly. Stretching is a good start. Light aerobic exercise such as walking, swimming, or riding a bicycle or stationary bike can also be helpful. Try to keep a balance between being active enough to benefit from it and exercising so much that you become overtired.
- Try taking nonprescription pain medicines to relieve muscle and joint pain and headaches caused by CFS. Medicines that may be helpful include acetaminophen (such as Tylenol), ibuprofen (such as Advil or Motrin), and naproxen (such as Aleve). Be safe with medicines. Read and follow all instructions on the label. Talk to your doctor if your pain is not relieved by nonprescription medicine.
- Join a support group. These groups can be a good source of information and tips for managing your illness. They also give you a chance to share your frustrations and problems with others who have CFS. Ask your doctor or contact a local hospital for the location of a support group near you.
- Eat a balanced diet. Include plenty of fruits, vegetables, grains, cereals, legumes, poultry, fish, lean meats, and low-fat dairy products.
Try to be patient. Keep in mind that daily home treatment usually helps relieve or control CFS symptoms. Your doctor may suggest cognitive-behavioral therapy to help you with your home treatment.
Medicines do not cure chronic fatigue syndrome (CFS). But they can help relieve your symptoms.
Over-the-counter medicines include:
- Pain relievers and anti-inflammatory drugs: Over-the-counter drugs include acetaminophen (for example, Tylenol), ibuprofen (for example, Advil, Motrin), and naproxen (for example, Aleve). They sometimes relieve frequent or severe joint and muscle pain, headaches, and fevers. Be safe with medicines. Read and follow all instructions on the label. Talk to your doctor if your pain is not relieved by nonprescription medicine.
Prescription medicines include:
- Anticonvulsants, also called antiseizure medicines. This type of drug, such as gabapentin and pregabalin, is sometimes prescribed for pain and sleep problems. It seems to work best when used for nerve pain.
- Antidepressants. Antidepressant medicine is prescribed by a doctor to ease depression and anxiety, improve your ability to concentrate, and help you sleep better.
- Narcotics. Narcotic medicine, such as tramadol, codeine or morphine, is sometimes prescribed by a doctor for pain that is not relieved by over-the-counter drugs. A narcotic is generally reserved for the most severe cases. Because of the risk of addiction, it is used only for a short time.
For more information about treating some types of pain that may occur with CFS, see:
What to think about
Some research has studied the use of corticosteroids (such as hydrocortisone and fludrocortisone) to treat chronic fatigue syndrome (CFS). Studies have shown that these medicines don't work very well to treat CFS. And the side effects can be serious. Unless corticosteroids can be shown to have a greater benefit for people with CFS over a longer period of time, the side effects associated with long-term corticosteroid therapy outweigh the benefits from their use in most cases.footnote 2
Depression often becomes a part of chronic fatigue syndrome and can make your symptoms worse. Like any medical illness, depression needs to be treated. If you have CFS and feel depressed, talk to your doctor and get treatment.
The best treatment for your chronic fatigue syndrome (CFS) is what makes you feel better. Along with daily self-care and the treatment you get from your doctor, you might find that other treatments help too.
There are safe nontraditional treatments that can relieve pain and stress, ease muscle tension, help you feel better and healthier, and improve your outlook and quality of life.
Some popular complementary treatments include:
There are many unproven treatments for CFS. Some of the more popular ones include:
- Large doses of vitamins or minerals. But taking too much of certain vitamins and minerals can actually be harmful.
- Diets that eliminate certain foods or ingredients (such as yeast, sugar, or food additives) that some people believe stress the immune system. Because the exact role of the immune system in CFS isn't well understood, there is no scientific basis for these remedies. But if certain foods seem to make your symptoms worse, there is no harm in avoiding them as long as you are eating a balanced diet.
- Aloe vera juice.
- Evening primrose oil.
- Royal jelly (a bee product).
What to think about
None of these complementary treatments have been proven effective in treating CFS, but some people have reported feeling better after using them. If you have CFS and are thinking about trying a complementary treatment, get the facts before you begin. Consider these questions with your doctor:
- Is it safe? Do not use treatments that could harm you, such as unusual diets or excessive vitamin or mineral supplements. (A daily multiple vitamin is okay. Try to avoid taking more than 100% of the recommended daily allowance for any vitamin or mineral unless your doctor prescribes it.)
- Is the product manufactured reliably? Vitamin and mineral supplements and herbal products are not subject to the same regulations as medicines. Ingredients may vary from one maker to another. Read the labels carefully, and choose well-known brands you trust.
- Does it work? It may be hard to tell whether a treatment is working. Keep in mind that when you get better after treatment, the treatment may not be the reason for your improvement. Symptoms of CFS often improve on their own. Or the treatment may be causing a placebo effect, which makes you feel better.
- How much does it cost? An expensive treatment that may or may not help you may not be worth the high cost. Beware of products or treatment providers who require a large financial investment up front or a series of costly treatments.
- Will it improve my general health? Even if complementary treatments are not effective in treating CFS, some of them are safe and healthy habits that may improve your general well-being and may be worth trying.
Avoid products that claim to have a "secret" ingredient or that claim to cure CFS. Currently, there is no cure for CFS. Any benefit reported as a result of using a product is most likely due to improved symptom management, chance, or, possibly, the illness running its course.
For more information, see the topic Complementary Medicine.
Other Places To Get Help
- Friedberg F, et al. (2012). Chronic fatigue syndrome/myalgic encephalomyelitis: A primer for clinical practitioners. International Association for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis. http://www.guideline.gov/content.aspx?id=38316#Section420. Accessed January 20, 2015.
- Reid S, et al. (2011). Chronic fatigue syndrome, search date March 2010. BMJ Clinical Evidence. Available online: http://www.clinicalevidence.com.
Other Works Consulted
- Bleijenberg G, Van Der Meer JWM (2012). Chronic fatigue syndrome. In DL Longo et al., eds., Harrison's Principles of Internal Medicine, 18th ed., vol. 2, pp. 3519–3521. New York: McGraw-Hill.
- Engleberg NC (2010). Chronic fatigue syndrome. In GL Mandell et al., eds., Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7th ed., pp. 1897–1904. Philadelphia: Churchill Livingstone Elsevier.
- Sadock BJ, Sadock VA (2007). Chronic fatigue syndrome. Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th ed., pp. 652–657. Philadelphia: Lippincott Williams and Wilkins.
- White PD, et al. (2011). Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): A randomised trial. Lancet, 377(9768): 823–826.
Primary Medical Reviewer Anne C. Poinier, MD - Internal Medicine
E. Gregory Thompson, MD - Internal Medicine
Specialist Medical Reviewer Nancy Greenwald, MD - Physical Medicine and Rehabilitation
Current as ofApril 29, 2015
Current as of: April 29, 2015
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