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Chronic Fatigue & ME/CFS

Exhaustion that rest doesn’t fix and that gets worse after even small efforts. Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a serious biological illness, not laziness or “just being tired” — and careful pacing, not pushing through, is the foundation of care.

See a doctor about new, unexplained fatigue. Fatigue is common and usually not due to a serious disease, but it can be a sign of one. Fatigue that isn’t relieved by enough sleep, good nutrition or a low-stress environment should be checked by your health care provider (MedlinePlus). Some causes, such as anemia and thyroid problems, can be checked with simple blood tests (MedlinePlus).

Get help right away if fatigue comes with confusion or dizziness, blurred vision, little or no urine, or recent swelling and weight gain (MedlinePlus). Call 911 for chest pain or pressure, or other heart attack symptoms such as shortness of breath, and some people — including women, older adults and people with diabetes — have little chest pain and feel mainly short of breath, tired and weak (MedlinePlus). Call 911 if someone faints and has chest pain, a pounding or irregular heartbeat, or doesn’t become alert within a couple of minutes (MedlinePlus).

If you are having thoughts of harming yourself, call or text 988 to reach the 988 Suicide & Crisis Lifeline — free, confidential and open 24/7 (988 Lifeline). In life-threatening situations, call 911 or go to the nearest emergency room (NIMH). Living with a long, misunderstood illness is hard, and you deserve support.

Beware the “push and crash” cycle. In ME/CFS, doing more on a good day to make up for lost time can lead to a crash — a worsening of symptoms (CDC). Standard exercise advice for healthy people can substantially harm people with ME/CFS (CDC), and the UK’s NICE advises against telling people with ME/CFS to go to the gym or exercise more, because this may worsen symptoms (NICE guideline NG206, 2021).

What is ME/CFS?

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a serious and often long-lasting illness that keeps people from doing their usual activities. It is a biological illness that affects many parts of the body, causing severe fatigue that rest doesn’t improve, problems thinking and sleeping, dizziness, pain and many other symptoms. People with ME/CFS may not look sick, yet about 1 in 4 are confined to bed at some point in their illness (CDC). CDC is clear that it is a biological illness, not a psychological disorder, and that patients are neither faking nor seeking to gain from being ill (CDC). Not all lasting fatigue is ME/CFS, though — see Ruling out other causes below.

Post-exertional malaise: the hallmark

Post-exertional malaise (PEM) is the hallmark of ME/CFS (CDC): a worsening of symptoms after physical, mental or emotional effort that would not have caused a problem before the illness. Symptoms typically worsen 12 to 48 hours after the activity and can last days or even weeks (CDC). CDC gives everyday examples: grocery shopping may require a nap in the car before driving home, showering may leave someone bed-bound for days, and working may mean spending nights and weekends recovering (CDC).

How it is diagnosed: the 2015 criteria

In 2015 the Institute of Medicine (now the National Academy of Medicine) published diagnostic criteria for ME/CFS in adults and children (CDC), which CDC has adopted (Mayo Clinic Proceedings, 2021). Diagnosis requires three symptoms:

  • A substantial reduction in activity compared with before the illness (at work, school, socially or at home) that lasts more than 6 months, with fatigue that is often profound, new rather than lifelong, not caused by unusual exertion and not substantially relieved by rest.
  • Post-exertional malaise (above).
  • Unrefreshing sleep — not feeling better after a full night’s sleep.

plus at least one of:

  • Cognitive impairment — problems with thinking, memory, attention and processing information, often made worse by exertion, standing, stress or time pressure.
  • Orthostatic intolerance — symptoms such as lightheadedness, fainting, headache or nausea that worsen when standing or sitting upright and improve (though not always fully) when lying down (CDC).

The core symptoms should be present at least half the time, at moderate, substantial or severe intensity (CDC). Pain, headaches and sensitivity to light and noise are also common (CDC). There is no test to confirm ME/CFS; clinicians rely on a thorough history and exam, laboratory tests and ruling out other illnesses (CDC).

How common is it, and who is affected?

A CDC analysis of the National Health Interview Survey found that in 2021–2022, 1.3% of U.S. adults had ME/CFS. Women (1.7%) were more likely than men (0.9%) to have it. It rose with age, from 0.7% at ages 18–39 to about 2% at ages 50–69, then fell to 1.4% at 70 and older. It was also more common in lower-income families and rural areas. Because the survey counted only people a doctor had diagnosed, the true number may be higher (NCHS Data Brief 488, CDC).

CDC estimates that up to 3.3 million people in the United States have ME/CFS and that more than 9 in 10 have not been diagnosed. It also affects children and teens, and many people from racial and ethnic minority groups are undiagnosed (CDC).

Infections, Long COVID and other triggers

The cause of ME/CFS is still unknown, and there may be more than one (CDC). It is increasingly viewed as an infection-associated chronic illness: up to 80% of patients develop it after an acute viral-like illness, although no single infection has been established as the cause (CDC). About 1 in 10 people infected with Epstein-Barr virus, Ross River virus or Coxiella burnetii (the cause of Q fever) later develop an illness like ME/CFS (CDC).

Long COVID. People have reported ME/CFS-like illness after COVID-19 (CDC), and the two illnesses share many symptoms (CDC). CDC defines Long COVID as a chronic condition that follows SARS-CoV-2 infection and lasts at least 3 months; there is no approved test or treatment for it (CDC). The National Institutes of Health created the RECOVER Initiative to understand, diagnose, prevent and treat Long COVID (NIH RECOVER). Because symptoms overlap, CDC says ME/CFS management approaches can help people with lasting symptoms after other infections too (CDC).

Ruling out other causes

Because no test confirms ME/CFS, ruling out other causes of fatigue is a key step. Your provider will ask about your history and symptoms and is likely to take blood and urine samples (CDC). Common, often treatable causes of fatigue include:

  • Anemia or iron deficiency.
  • An underactive or overactive thyroid.
  • Sleep disorders such as insomnia, obstructive sleep apnea or narcolepsy.
  • Depression or grief.
  • Diabetes, kidney or liver disease, heart failure, autoimmune diseases, cancer, and long-lasting infections.
  • Medicines — including antihistamines, blood pressure medicines, sleeping pills, steroids and water pills — and alcohol or drug use (MedlinePlus).

Tests may include blood tests for anemia, diabetes, inflammation and infection, kidney, liver and thyroid function tests, and a urinalysis (MedlinePlus). You may be referred to a neurologist, rheumatologist or sleep specialist; they may find another condition to treat instead of, or as well as, ME/CFS (CDC). Fibromyalgia also causes fatigue (MedlinePlus); a separate Fibromyalgia guide is coming. If you have been unwell for 6 months or more but don’t fully meet the criteria, CDC says you can be managed like a patient with ME/CFS and monitored for change (CDC).

What to expect over time

ME/CFS ranges from mild to severe. How many people recover is not well studied: some return to full function, many who improve still have symptoms, and remissions can be followed by relapses. Experts generally agree that children and teens have a better chance of full or partial recovery than adults, and early diagnosis and appropriate management may play a role (CDC).

Side by side

Six approaches compared

For every condition we look at the same six approaches: what each involves, what it typically costs, and what a patient can realistically expect.

ApproachWhat it involves Estimated costWhat to expect
Conventional medicine (AMA) Ruling out other causes with blood and urine tests, then treating the most disruptive symptoms: pacing for post-exertional malaise, sleep, pain, dizziness on standing, memory problems, and depression or anxiety. CBT can support coping. Graded exercise therapy is no longer recommended. Therapy about $80–$200 a session at market rates, or $40–$70 through a nonprofit sliding-scale network. Doctor visits and blood tests: cost estimate being researched. There is no cure and no medicine approved specifically for ME/CFS. Treating symptoms helps some people but not others. People with ME/CFS are often sensitive to medicines, so prescribers may start low. CBT may ease distress but is not a cure.
Chiropractic No credible evidence that chiropractic care helps ME/CFS. Not applicable. Not a treatment for ME/CFS. We found no trials of chiropractic or spinal manipulation for it.
Acupuncture Needle sessions, sometimes offered for pain alongside usual care. About $125–$230 for a first private visit and $90–$185 for follow-ups; community clinics about $50–$90. CDC says acupuncture by a licensed practitioner might help pain for some people. Studies for ME/CFS itself are mostly low quality, so no firm conclusions can be drawn. Travel and appointments can trigger a crash — plan rest.
Herbal medicine No supplement is proven for ME/CFS. NADH, CoQ10, D-ribose, ginseng and others have been tried in small studies. Cost estimate being researched. Some small studies reported less fatigue, but they had a high risk of bias and can’t support firm conclusions. Supplements are unregulated, can cause side effects and can interact with medicines. Many products sold as cures are unproven.
Massage therapy Gentle massage for pain, relaxation and stress. About $50–$90 for 45–60 minutes at clinics and spas; $60–$120 with an independent therapist. CDC lists gentle massage among approaches that may help pain and stress for some people. Trials for ME/CFS are low quality. Generally low risk; avoid deep, vigorous work.
MBHA Wellness Coach Pacing and staying within your energy envelope, activity and symptom diaries, optional heart-rate monitoring, planned rest, sleep habits, managing crashes, workplace or school accommodations, disability paperwork, and support for you and your caregivers. Cost estimate being researched. Pacing isn’t a cure, but it can reduce crashes and may stabilize or improve symptoms. A coach supports you and never pushes you past your limits or replaces medical care.

Approach 1 of 6

Conventional medicine (AMA)

There is no cure or approved treatment for ME/CFS, but some symptoms can be treated or managed. You, your family and your health care providers should decide together which symptom causes the most problems and treat that first, after discussing the possible benefits and harms (CDC). No medicines are approved specifically for ME/CFS (Job Accommodation Network), and NICE advises that no medicine or supplement should be offered as a cure (NICE). Care starts with ruling out other causes (see above); an activity and symptom diary can help you remember important details at visits (CDC).

1. Treating the most troublesome symptoms

  • Post-exertional malaise: managed with pacing — see Pacing and energy management below (CDC).
  • Sleep: good sleep habits first, then sleep medicines for the shortest time possible if needed; a sleep specialist can check for sleep apnea or narcolepsy (CDC).
  • Pain: over-the-counter pain relievers first, then a pain specialist if needed. Stretching, manual physical therapy, gentle massage, heat and water therapy help some people, but must be planned carefully to avoid PEM (CDC).
  • Dizziness on standing (orthostatic intolerance): your provider may check your heart rate and blood pressure while you stand and refer you to a cardiologist or neurologist. Avoiding heat and long periods of standing, and compression garments, can help. More salt and fluids helps some people whose intake is low, but it is not safe with high blood pressure, kidney failure or heart failure — only do this on your clinician’s advice. Prescription medicines are an option if these steps don’t help (CDC).
  • Memory and concentration: organizers, calendars and phone reminders help. Stimulant medicines may help some people concentrate, but they can trigger the push-and-crash cycle (CDC).
  • Depression and anxiety: as many as half of people with ME/CFS develop depression at some point. It should be treated — though treating it does not cure ME/CFS (CDC). Some antidepressants can worsen other ME/CFS symptoms, so they are prescribed with caution (CDC). See our Anxiety guide.

A note on medicines: people with ME/CFS are often more sensitive to medicines and may need less than the usual dose; all medicines and supplements should be reviewed regularly for side effects and interactions (CDC). We don’t list doses here — your prescriber will.

2. Cognitive behavioral therapy: support, not a cure

NICE says CBT has sometimes been wrongly assumed to be a cure for ME/CFS. It should be offered only to help people manage symptoms, improve functioning and reduce the distress of living with a chronic illness, only if the person wants it, and only from a therapist trained in ME/CFS. It does not assume that “abnormal” illness beliefs cause ME/CFS (NICE). People have found it useful when delivered by a therapist who understands ME/CFS, but it can cause harm when delivered inappropriately (NICE). Counseling about coping with the illness may help (CDC).

3. Why graded exercise therapy is no longer recommended

For years, CDC recommended a program of steadily increasing activity and a specific form of CBT; in early July 2017 it removed them from the main section of its ME/CFS website (Undark, 2017). A 2021 consensus of U.S. ME/CFS clinicians notes that the United States, other governments and major health organizations have withdrawn graded exercise and CBT as the treatment of choice (Mayo Clinic Proceedings, 2021).

In 2021, NICE recommended against offering graded exercise therapy — which it defines as setting a baseline of activity and then making fixed, step-by-step increases — as well as any exercise therapy offered as a cure and general exercise programs designed for healthy people or other illnesses (NICE). The committee cited harms reported by people with ME/CFS and its own experience of what happens when people exceed their energy limits (NICE). NICE also advises against the Lightning Process (NICE).

The research is still debated: a Cochrane review of older trials (searches up to 2014) found exercise therapy probably reduced fatigue at the end of treatment compared with usual care, but was uncertain about harms and noted that people diagnosed under other criteria may respond differently. Cochrane has since discontinued a project to develop an update (Cochrane review, 2019, editorial note 2024). Current CDC and NICE guidance is what MBHA follows: exercise is not a cure, and any activity plan must be individual, flexible and stay within your limits (CDC). If you want to build activity, NICE says the program should be overseen by a physiotherapist in an ME/CFS specialist team, start below your baseline and be adjusted flexibly, up or down (NICE).

4. Children, teens and severe ME/CFS

  • Helping children stay in school and connected with friends is a priority. A study plan or an Individualized Educational Plan (IEP) may help; some children need part-time school or home tutoring (CDC).
  • People with very severe ME/CFS may need home visits, a quiet darkened room, a minimal medicine plan and gentle range-of-motion exercises if touch can be tolerated (CDC).

What it costs

  • Therapy without insurance: the nonprofit Open Path Collective puts typical U.S. market rates at about $80–$200 a session. Its network offers sliding-scale sessions of $40–$70 after a one-time $65 membership fee, for people without insurance or adequate mental health coverage (Open Path Collective).
  • Doctor visits, blood tests, sleep studies and specialist care: cost estimate being researched. ME/CFS has its own diagnosis code (G93.32), which CDC says makes it easier to bill for ME/CFS care (CDC).
  • For disability benefits, see Work, school, benefits and support below.

How well it works — what to expect

If another cause such as anemia, a thyroid problem or sleep apnea is found, treating it can make a real difference. For ME/CFS itself, treating symptoms may bring relief for some people but not others, and learning new ways to manage activity can also help (CDC). Be cautious about anything sold as a cure: many such treatments are unproven, often costly and could be dangerous (CDC).

Find a medical doctor in our directory

Approach 2 of 6

Chiropractic

We found no credible evidence that chiropractic care helps ME/CFS. A PubMed search for chiropractic, spinal manipulation or osteopathic care in ME/CFS turned up no relevant trials, and neither CDC’s management advice nor NICE’s recommendations mention chiropractic care (CDC, NICE).

If you see a chiropractor for back or neck pain, that is a separate question. Tell them you have ME/CFS, avoid anything vigorous, and plan rest around the visit — for some people even attending medical appointments can worsen symptoms (Job Accommodation Network). Gentle approaches such as stretching and manual physical therapy are discussed under conventional care.

Find a chiropractor in our directory

Approach 3 of 6

Acupuncture

CDC says acupuncture, when done by a licensed practitioner, might help with pain for some people with ME/CFS (CDC). Evidence that it helps ME/CFS itself is weak.

What the research says

A 2019 review of 16 trials (1,346 people) found acupuncture seemed to do better than sham acupuncture and Chinese herbal medicine on fatigue. But most studies were of low quality, the certainty of the evidence was low, and the authors said no firm conclusion could be reached because of limited data and possibly exaggerated effects (systematic review, Acupuncture in Medicine, 2019). NICE’s 2021 recommendations on ME/CFS do not mention acupuncture (NICE).

Safety and practical tips

  • Relatively few complications have been reported; problems have come from non-sterile needles and improper technique. FDA requires acupuncture needles to be sterile and single-use (NCCIH).
  • Count travel and the session itself as exertion. Choose shorter or less frequent visits, and plan rest afterward, so treatment doesn’t trigger PEM.

What it costs

Published cash prices run about $125–$230 for a first private visit and $90–$185 for follow-ups; community clinics about $50–$90 a visit (The Pricer).

Find an acupuncturist in our directory

Approach 4 of 6

Herbal medicine

No herb or supplement has been proven to treat ME/CFS. NICE says there is not enough evidence to support routinely taking vitamin and mineral supplements as a cure or to manage symptoms (NICE). People with ME/CFS often use supplements, but they are unregulated and information on potency and side effects is often unknown, so talk with your provider before starting any (CDC).

What the research says

Interactions and safety

  • CoQ10 may interact with the blood thinner warfarin and with insulin (NCCIH).
  • Asian ginseng might lower blood sugar and might interact with some medicines; people who take medicines should talk with their health care providers first (NCCIH).
  • If you choose to take a vitamin or supplement, ask about side effects of taking more than the recommended daily amount (NICE). We don’t list doses here.
  • People with ME/CFS may be at risk of low vitamin D, especially if they are housebound or bedbound — ask your clinician whether to check it (NICE).

Approach 5 of 6

Massage therapy

CDC lists gentle massage among the approaches that may help some people with ME/CFS with pain, stress and anxiety, alongside heat, stretching and relaxation techniques (CDC, CDC).

What the research says

A 2024 review of 32 trials (2,594 people) reported less fatigue with massage, mainly traditional Chinese massage (tuina). However, all the trials were published in China, most did not use blinding, and the authors themselves describe the study designs as not rigorous enough and the quality of the evidence as relatively low (systematic review, Medicine, 2024). In short: massage may help you relax and ease pain, but it is not a treatment for ME/CFS.

Practical tips

  • Ask for gentle pressure. The risk of harm from massage appears low, but rare serious side effects have mostly involved vigorous techniques such as deep tissue massage (NCCIH).
  • Some people with ME/CFS are sensitive to light, sound, touch and smell (Job Accommodation Network) — ask for a quiet, dim, unscented room, and consider shorter sessions or a home visit.
  • Plan rest after the session, and count travel as exertion.

What it costs

About $50–$90 for 45–60 minutes at clinics, gyms and spas, or $60–$120 with an independent therapist; massage schools sometimes charge less (CostHelper).

Find a massage therapist in our directory

Approach 6 of 6

MBHA Wellness Coach

An MBHA Wellness Coach can help you build the daily habits behind pacing, protect your energy and stay connected. A coach will never push you past your limits, doesn’t diagnose or treat, and works alongside your medical care.

Pacing and your energy envelope

The core of coaching is the approach in Pacing and energy management below. A coach can help you keep simple diaries, break big tasks into smaller steps, and plan rest before and after demanding days.

Sleep habits

Good sleep habits matter for everyone with ME/CFS (CDC). A coach can help you set a regular wind-down routine and track sleep to share with your clinician. Intense, vivid dreams are a common sleep complaint in ME/CFS (CDC); if nightmares are a problem, see our Bad Dreams guide.

Calming the body

Deep breathing, muscle relaxation and gentle movement such as stretching, yoga or tai chi can reduce stress for people with less severe ME/CFS, but starting them needs care to avoid PEM (CDC). Relaxation techniques are generally considered safe (NCCIH).

Work, school and paperwork

A coach can help you prepare an accommodation request, organize records for a disability application, and plan how to talk with an employer or school — see Work, school, benefits and support below.

Support for you and your family

Families also need support as they learn to live with ME/CFS (CDC). A coach can help you find peer support groups and caregiver resources, explain PEM to loved ones, and notice when it’s time to seek counseling.

Another approach

Pacing and energy management

Pacing — also called activity management or energy management — is the main way to manage post-exertional malaise. The goal is to balance activity and rest to avoid PEM flare-ups (CDC). It isn’t a cure (NICE), but the Job Accommodation Network notes that pacing can lead to stabilization or improvement in pain, sleep, fatigue and thinking, can prevent symptoms worsening, and may improve quality of life considerably (Job Accommodation Network).

Find your energy envelope

  • Learn your limits. Each person has different limits for physical and mental activity. Staying within them is sometimes called staying within your “energy envelope.” Activity and symptom diaries can help you find your limits, especially early in the illness (CDC).
  • Count every kind of effort. Energy management covers cognitive, physical, emotional and social activity, and each person’s limit fluctuates (NICE). Everyday activities such as buying groceries, brushing your teeth or talking with others can bring on PEM (CDC).
  • Start at a sustainable level, which may mean doing less at first. Plan periods of rest and activity, including rest before you need it, and alternate different kinds of activity in small chunks (NICE).

Avoid the push-and-crash cycle

On a good day it is tempting to do more to make up for lost time — but this can lead to a crash, and the cycle can repeat as you recover (CDC). Because PEM often starts 12 to 48 hours later (CDC), you may not feel the cost of a busy day until a day or two later. When you do improve, activity can be increased cautiously, watching for any setback (CDC); NICE says activity should never be increased automatically, only adjusted up after a period of stability or down when symptoms are worse (NICE).

Tools that can help

  • Heart-rate monitoring. Some patients find a heart-rate monitor helps them track how hard their body is working and prevent PEM (CDC). NICE suggests using tools you already have, such as an activity tracker, phone heart-rate monitor or diary (NICE). Ask your clinician how to use the readings — we don’t give target numbers here.
  • Make tasks easier: sit to do laundry or shower, take frequent breaks and break big jobs into smaller steps (CDC).
  • Simple tracking: if you are very unwell, pen and paper or a phone calendar is fine (Solve M.E.).
  • Specialist help: rehabilitation specialists or exercise physiologists who understand ME/CFS may help you adapt (CDC); NICE recommends a physiotherapist or occupational therapist in an ME/CFS specialist team (NICE).

Managing a crash

A crash may take days, weeks or longer to recover from (Job Accommodation Network). NICE advises including a plan for flare-ups and relapses in your energy management plan (NICE) — for example, what you will cancel and who can help.

Pacing is not the same as graded exercise. Graded exercise therapy asks you to keep increasing activity over time, which can repeatedly trigger PEM; many patients have reported it as harmful (Solve M.E.). If any program asks you to push through symptoms, stop and talk with your clinician.

Another approach

Work, school, benefits and support

ME/CFS often makes it hard to keep a job, go to school and take part in family and social life (CDC). With careful planning, people with mild ME/CFS may be able to keep working or studying; people with moderate ME/CFS may have trouble keeping a regular schedule (CDC).

Your rights at work

The Americans with Disabilities Act protects people with a physical or mental impairment that substantially limits one or more major life activities; its employment rules apply to employers with 15 or more employees (ADA.gov). The ADA has no list of qualifying conditions, not everyone with ME/CFS needs accommodations, and many need only a few (Job Accommodation Network). Occupational counseling can help identify accommodations and ways to save energy (CDC).

Accommodation ideas from the Job Accommodation Network

  • For fatigue: a flexible schedule, periodic rest breaks, job restructuring, task rotation, telework, and seating or ergonomic changes.
  • For dizziness: a modified break schedule, a flexible schedule or telework.
  • For memory problems: calendars and planners, memory apps, electronic organizers and extra training time.
  • For sleep problems: a flexible or modified break schedule (Job Accommodation Network).

For students, a study plan or an IEP may help, and some need part-time school or home tutoring (CDC).

Disability benefits

If you can’t work, you can apply for disability benefits through the Social Security Administration (SSA). SSA has a specific policy for evaluating ME/CFS, called SSR 14-1p, last updated in April 2014; your doctor can help by keeping good notes and tracking your health status (CDC). Solve M.E. encourages people who can’t work, or are struggling to keep working, not to hesitate to apply for disability insurance, and publishes a disability guide (Solve M.E.).

Support for patients and caregivers

  • Solve M.E. offers resources on symptom tracking, pacing, finding a doctor, work and finances, mental health, and caregiver support, plus a list of online support groups (Solve M.E.).
  • #MEAction runs online support groups, including groups for people living with ME, for Long COVID, for parents with ME and for caregivers (#MEAction).
  • Caregivers matter too. Caregivers of people with severe ME/CFS often face substantial stress and may need extra support (CDC). Counseling can help people with severe ME/CFS adjust their expectations and deal with the anger, frustration and despair that can come with a debilitating illness (CDC).

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