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Moderate Evidence

Promising research with growing clinical support from multiple studies

Chronic Fatigue Syndrome / Myalgic Encephalomyelitis (CFS/ME)

Chronic Fatigue Syndrome, also termed Myalgic Encephalomyelitis (ME/CFS), is a complex, multi-system illness characterized by profound fatigue, marked reduction in pre-illness activity, non-restorative sleep, cognitive difficulties, orthostatic intolerance, and especially post-exertional malaise (PEM)—a delayed exacerbation of symptoms after physical, cognitive, or emotional exertion. PEM is now widely recognized as the cardinal feature of ME/CFS and a key differentiator from primary depression or simple deconditioning. Onset can be sudden (often after an infection) or gradual, and severity ranges from mild functional limitation to complete home- or bed-bound states. The condition affects quality of life at levels comparable to other serious chronic diseases, yet no single biomarker or curative therapy has been validated to date. Western medicine conceptualizes ME/CFS as a neuroimmune and metabolic disorder evaluated by clinical criteria and exclusion of alternative explanations. Multiple diagnostic frameworks exist, including the Fukuda (1994) criteria, the Canadian Consensus Criteria (2003), and the Institute of Medicine/National Academy of Medicine criteria (2015; Systemic Exertion Intolerance Disease, SEID). All emphasize substantial impairment and persistent fatigue not alleviated by rest, with the IOM/SEID requiring PEM, unrefreshing sleep, and either cognitive impairment or orthostatic intolerance. Research has described autonomic dysregulation, immune activation and heterogeneously altered cytokines, small-fiber neuropathy in some patients, cerebral hypoperfusion, reduced aerobic capacity with abnormal repeat cardiopulmonary exercise testing, and gastrointestinal dysbiosis. Immune-modulating therapies such as rituximab that showed early promise have failed in larger, rigorous trials. Microbiome work reveals compositional and functional differences and links to symptom severity, but interventional evidence remains preliminary. Management in contemporary, (e

Chronic illness Updated February 19, 2026

This content is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare provider before starting, stopping, or changing any supplement or medication regimen.

Western Medicine

Diagnosis

Clinical diagnosis using established criteria after exclusion of alternative causes. Common frameworks: Fukuda (1994), Canadian Consensus Criteria (2003), and IOM/SEID (2015). Key features include substantial functional reduction for >6 months, post-exertional malaise (PEM), unrefreshing sleep, cognitive dysfunction (“brain fog”), pain, and orthostatic intolerance. Workup is targeted to rule out endocrine, hematologic, autoimmune, sleep, infectious, and psychiatric differentials; autonomic testing and 2-day CPET may support phenotype but are not required.

Treatments

  • Education and pacing/energy-envelope management to prevent PEM; activity is tailored to symptom-contingent thresholds rather than fixed graded increases
  • Symptom-targeted care: sleep optimization (sleep hygiene; address circadian issues; treat sleep apnea/PLMs if present)
  • Orthostatic intolerance management: fluids, salt, compression garments; medications such as fludrocortisone, midodrine, beta-blockers or ivabradine (off-label) as appropriate
  • Pain management: non-opioid analgesics; SNRIs, TCAs, or gabapentinoids when indicated; headache-specific therapies
  • Cognitive support and accommodations (task chunking, memory aids); consider occupational/rehabilitation therapy experienced with ME/CFS
  • CBT as an adjunct for coping and symptom management (not curative); avoid approaches that promote “pushing through” PEM
  • Careful, individualized physical rehabilitation within the energy envelope; avoid graded exercise therapy (GET) that prescribes fixed incremental increases
  • Address comorbidities (MCAS-like symptoms, POTS, IBS, migraine, anxiety/depression)
  • Nutrition support; manage GI issues; consider diet patterns tolerated by the patient
  • Research/experimental domains: immune modulation (largely negative for rituximab), microbiome-directed therapies (investigational)

Medications

  • Sleep: low-dose amitriptyline or doxepin, trazodone, melatonin, gabapentin/pregabalin when appropriate
  • Orthostatic intolerance: fludrocortisone, midodrine, beta-blockers (e.g., propranolol), ivabradine (off-label), pyridostigmine (select cases)
  • Pain: NSAIDs/acetaminophen; SNRIs (duloxetine), TCAs, gabapentinoids; migraine-specific agents
  • Fatigue/cognition (select patients): modafinil/armodafinil, methylphenidate (off-label; monitor for PEM exacerbation)
  • Low-dose naltrexone (off-label; emerging evidence)
  • Antivirals or immunotherapies: inconsistent/limited evidence; not routinely recommended outside research

Limitations

No validated biomarker or disease-modifying therapy; heterogeneity complicates trials and clinical decisions. Interventions that increase activity can worsen PEM; historical support for graded exercise (PACE) has been strongly criticized and is no longer recommended by NICE. Pharmacologic options are largely symptomatic with variable responses and potential side effects. Research on immune and microbiome targets is promising but not yet practice-changing.

Evidence: Moderate Evidence

Sources

  • National Institute for Health and Care Excellence (NICE). Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management. NG206; 2021. https://www.nice.org.uk/guidance/ng206
  • Fukuda K et al. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med. 1994;121(12):953-959. https://pubmed.ncbi.nlm.nih.gov/7978722/
  • Carruthers BM et al. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Canadian Consensus Document. J Chronic Fatigue Syndr. 2003;11(1):7-36.
  • Institute of Medicine. Beyond ME/CFS: Redefining an Illness (SEID). National Academies Press; 2015. https://nap.nationalacademies.org/catalog/19012
  • White PD et al. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for CFS (PACE): RCT. Lancet. 2011;377:823-836. https://pubmed.ncbi.nlm.nih.gov/21334061/
  • Wilshire C et al. Rethinking the treatment of CFS: a reanalysis of the PACE trial. BMC Psychol. 2018;6:6. https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-018-0218-3
  • Fluge Ø et al. B-Lymphocyte Depletion in ME/CFS (RituxME): RCT. Ann Intern Med. 2019;170(9):585-593. https://pubmed.ncbi.nlm.nih.gov/30934066/
  • Giloteaux L et al. Reduced diversity and altered composition of the gut microbiome in ME/CFS. Microbiome. 2016;4:30. https://microbiomejournal.biomedcentral.com/articles/10.1186/s40168-016-0171-4

Eastern & Traditional Medicine

Traditional Chinese Medicine (TCM)

Frames ME/CFS as patterns of deficiency and dysregulation—commonly spleen and lung qi deficiency (fatigue, poor appetite), kidney yang or yin deficiency (cold/heat intolerance, low back/knee weakness, sleep issues), and liver qi stagnation (mood, tension). Treatment aims to tonify qi and kidney essence, harmonize liver, transform dampness/phlegm, and calm shen, applied iteratively as the presentation evolves.

Techniques

  • Individualized herbal formulas such as Bu Zhong Yi Qi Tang (qi tonification), Liu Wei Di Huang Wan (kidney yin), Jin Gui Shen Qi Wan (kidney yang), and modifications for damp-heat or phlegm
  • Acupuncture with gentle dosing (common points: ST36, SP6, CV6, CV12, KI3, LR3, GV20; low frequency to avoid provoking PEM)
  • Gentle qigong/breathwork within the patient’s energy envelope; emphasis on restorative rather than exertional practice
Licensed acupuncturist/TCM physician Herbalist trained in Chinese materia medica
Evidence: Traditional Use

Acupuncture (as a focused modality)

Used to modulate autonomic tone, sleep quality, pain, and perceived fatigue; treatment is titrated to avoid post-needling fatigue flares. Often combined with moxibustion or gentle electroacupuncture at low intensity.

Techniques

  • Body acupuncture with low needle count and shorter retention times
  • Moxibustion for yang/qi deficiency presentations
  • Electroacupuncture at low frequency in selected cases
Licensed acupuncturist MD/DO with medical acupuncture training
Evidence: Emerging Research

Ayurveda (Rasayana/rejuvenation)

Conceptualizes ME/CFS as ojokshaya (depletion of vital essence) with vata-pitta imbalance. Rasayana aims to restore vitality through tailored diet, daily routines (dinacharya), gentle yoga/breathing within tolerance, herbal rasayanas (e.g., Ashwagandha, Amalaki, Guduchi), and gradual convalescence practices.

Techniques

  • Rasayana formulations (e.g., Ashwagandha preparations, Chyawanprash)
  • Gentle yoga, pranayama, meditation adapted to avoid PEM
  • Dietary measures to support agni (digestion) without overexertion
Ayurvedic physician (BAMS) Integrative medicine clinician with Ayurvedic training
Evidence: Traditional Use

Adaptogenic herbs (cross-traditional)

Adaptogens such as Ashwagandha (Withania somnifera), Rhodiola rosea, and Eleutherococcus senticosus are used to support stress-response systems, perceived energy, and cognition. Evidence supports modest benefits for fatigue and stress in heterogeneous populations; ME/CFS-specific data are limited, so careful, low-dose trials are advised.

Techniques

  • Standardized Ashwagandha extracts (e.g., 240–600 mg/day)
  • Rhodiola SHR-5/WS standardized extracts (e.g., 200–400 mg/day)
  • Eleuthero root extracts (dosing per product and practitioner guidance)
Naturopathic doctor Herbalist Integrative/functional medicine clinician
Evidence: Moderate Evidence

Sources

  • Wang T et al. Acupuncture for chronic fatigue syndrome: systematic review and meta-analysis. Acupunct Med. 2017;35(5):333-339.
  • Cho NH et al. Traditional Chinese Medicine for CFS: narrative/systematic reviews (various).
  • Ng SM et al. Self-practice Qigong for CFS: randomized controlled trial. Trials. 2012;13:111. https://trialsjournal.biomedcentral.com/articles/10.1186/1745-6215-13-111
  • Wang T et al. Acupuncture for CFS: meta-analysis. Acupunct Med. 2017;35(5):333-339.
  • Kim SY et al. Acupuncture for CFS: systematic review of RCTs. BMC Complement Altern Med. 2012;12:167.
  • Kumar G et al. Rasayana therapy: concepts and clinical applications. Ayu. 2012;33(4):489-492.
  • Rao R et al. Traditional Ayurvedic rejuvenation approaches for chronic fatigue states: reviews/case series.
  • Panossian A, Wikman G. Effects of adaptogens on the CNS and fatigue. Phytomedicine. 2010;17(7):481-493.
  • Darbinyan V et al. Rhodiola SHR-5 in fatigue: RCT. Phytomedicine. 2000;7(5):365-371.
  • Chandrasekhar K et al. Ashwagandha in stress/anxiety with fatigue outcomes: RCT. Indian J Psychol Med. 2012;34(3):255-262.

Integrative Perspective

Across paradigms, pacing is the cornerstone: patients should avoid fixed, graded increases in activity that risk triggering post-exertional malaise (PEM). Both Western guidance (e.g., NICE 2021) and Eastern modalities emphasize gentle, symptom-contingent progression, restorative practices, and individualized dosing. ME/CFS involves impaired recovery and abnormal physiological responses to exertion (autonomic, metabolic, and possibly immune). For this reason, any intervention that raises activity load—even well-meaning physical therapy, vigorous yoga, or frequent acupuncture sessions—can precipitate crashes. Safer strategies include: establishing an energy envelope; pre-emptive rest; dividing tasks; prioritizing orthostatic management; and introducing therapies one at a time at low dose with extended monitoring. Nutraceuticals and herbs may offer incremental benefits for subsets but should be trialed judiciously to avoid overstimulation or interactions. Collaborative care that blends symptom-informed Western management with conservative Eastern supportive therapies can improve quality of life while minimizing relapse risk.

Sources

  1. National Institute for Health and Care Excellence (NICE) NG206. 2021. https://www.nice.org.uk/guidance/ng206
  2. Institute of Medicine/NAM. Beyond ME/CFS: Redefining an Illness (SEID). 2015. https://nap.nationalacademies.org/catalog/19012
  3. Fukuda K et al. Ann Intern Med. 1994;121:953-959. https://pubmed.ncbi.nlm.nih.gov/7978722/
  4. Carruthers BM et al. J Chronic Fatigue Syndr. 2003;11(1):7-36.
  5. White PD et al. Lancet. 2011;377:823-836. https://pubmed.ncbi.nlm.nih.gov/21334061/
  6. Wilshire C et al. BMC Psychol. 2018;6:6. https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-018-0218-3
  7. Fluge Ø et al. Ann Intern Med. 2019;170:585-593. https://pubmed.ncbi.nlm.nih.gov/30934066/
  8. Giloteaux L et al. Microbiome. 2016;4:30. https://microbiomejournal.biomedcentral.com/articles/10.1186/s40168-016-0171-4
  9. Ng SM et al. Trials. 2012;13:111. https://trialsjournal.biomedcentral.com/articles/10.1186/1745-6215-13-111
  10. Panossian A, Wikman G. Phytomedicine. 2010;17(7):481-493.
  11. Forsyth LM et al. NADH in CFS: RCT. Ann Allergy Asthma Immunol. 1999;82(2):185-191.
  12. Castro-Marrero J et al. CoQ10±NADH for fatigue/ME-CFS: clinical studies and reviews (e.g., Nutrients 2020–2022).

Health Disclaimer

This content is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare provider before starting, stopping, or changing any supplement or medication regimen.