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Symptomatic Treatment
People with CFS present with different patterns of primary symptoms. Symptom severity can also vary considerably. Clinicians should query patients 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.

Primary symptoms may include sleep problems, muscle and joint pain, cognitive dysfunction, fatigue, headaches and sore throat. Gastrointestinal complaints, orthostatic instability, depression and allergies are also seen in many patients. Aggressive symptom management for these and other disruptive symptoms is indicated.

Pharmacologic Therapy
Pharmacologic therapy is directed toward the relief of specific symptoms experienced by the individual patient. There are many over-the-counter and prescription drug therapies that can be used to treat sleep difficulties, cognitive problems, pain and other symptoms of CFS.

Many CFS patients are sensitive to medications, particularly sedating medications. Therapeutic benefits can often be achieved at lower than normal dosages, so try prescribing a fraction of the usual recommended dose to start and gradually increase as necessary and as tolerated. All medications can cause side effects, which may lead to new symptoms or exacerbate existing symptoms, so it is important to routinely monitor all prescription drugs, OTC therapies and supplements the patient is taking.

Some drugs act on multiple body systems and symptoms. For instance, tricyclic antidepressants may not only improve mood, but may help with sleep and pain. Prescribing such drugs allows the use of fewer medications to address multiple symptoms with minimal side effects.

Nutritional and Herbal Supplements
Nutritional supplements and vitamins are frequently used by people with CFS for symptom relief. While there have been few clinical trials and many CFS patients report symptom relief with supplements, these products are unregulated, and information on potency and side effects is frequently unknown. The health care professional needs to question patients about supplement use and OTC products to determine safety, efficacy and possible negative interactions with prescribed medications and therapies
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Patients should be advised to avoid herbal remedies like comfrey, ephedra, kava, germander, chaparral, bitter orange, licorice root, yohimbe and any other supplements that are potentially dangerous.

Nutritional supplements can't take the place of good diet and nutrition and, as such, a well-balanced diet should be encouraged. Some people with CFS report sensitivities to various foods or chemicals, including refined sugar, caffeine, alcohol and tobacco, all of which should be minimized to promote optimum health.

Alternative Therapies
Alternative therapies are often explored by CFS patients to relieve symptoms. Encourage patients to discuss such options with a health care professional to make sure they are safe and effective. Acupuncture, aquatic therapy, gentle massage, meditation, deep breathing, biofeedback, yoga, tai chi and massage therapy have been found to help some patients and are often prescribed for CFS symptom management.

Sleep Disturbances
The majority of CFS patients experience some form of sleep dysfunction. Common sleep complaints include difficulty falling asleep, hypersomnia, frequent awakening, intense and vivid dreaming, restless legs and nocturnal myoclonus. Most CFS patients experience nonrestorative sleep as compared to their pre-illness experience.

Health professionals 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; and avoid caffeine, alcohol and tobacco. Light exercise and stretching earlier in the day, at least four hours before bedtime, may also improve sleep.

When sleep hygiene isn't successful, the use of pharmaceuticals may be indicated. Initial medications to consider are simple antihistamines or over-the-counter sleep products. If this isn't beneficial, then 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 requisite hours of sleep. A sleep specialist should evaluate patients whose sleep remains non-restorative following standard interventions.

Primary sleep disorders such as sleep apnea and narcolepsy exclude the diagnosis of CFS, and most people with such disorders respond to therapy. It is imperative to obtain a careful sleep history. The Pittsburgh Sleep Questionnaire, a validated 19-question tool, or a brief sleep survey adapted from the CDC Symptom Inventory can be useful in assessing sleep problems and tracking effectiveness of sleep management interventions.

Pain
CFS pain occurs both in muscles (sometimes described as "deep pain") and joints (arthralgias). Patients may also complain of headaches (typically pressure-like) and allodynia, which is generalized hyperalgesia or soreness of the skin to touch.

Most pain therapy begins with simple analgesics like acetaminophen, aspirin or NSAIDS..Additional therapy can be managed by a pain specialist. Counseling for pain management techniques is advisable for patients with this kind of unremitting pain.

Pain management should include nonpharmacological modalities and alternative therapies. Stretching and movement therapies, gentle massage, heat, toning exercises, hydrotherapy and relaxation techniques can be helpful for CFS care. Acupuncture, when administered by a qualified practitioner who is knowledgeable about CFS, may be effective for pain management in some patients.

Orthostatic Instability
Some patients with CFS may also exhibit symptoms of orthostatic instability, in particular frequent dizziness and light-headedness.

Depending on severity and clinical judgment, these patients should be referred for evaluation by a cardiologist or neurologist. Specific treatment for orthostatic instability should only be initiated 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 don't have heart or blood vessel disease. If symptoms don't improve with increased fluid and salt intake, prescription medications and support hose can be prescribed.

During office visits, provide a place for CFS patients to recline if they have difficulty staying upright for more than a few minutes at a time.

Depression
Research shows that CFS is not a form of psychiatric illness or depression. However, many people with chronic illnesses, including those with CFS, may suffer from secondary depression as the patient makes the multiple adjustments to having a debilitating, chronic illness.

As many as half of CFS patients develop depression sometime during the course of the illness. When it's present, it needs to be treated. Although treating depression can reduce anxiety and stress, it's not a cure for CFS.

Professionals are advised to use caution in prescribing antidepressants. Antidepressant drugs of various classes have other effects that may act on other CFS symptoms and/or cause side effects.

There are brief psychiatric screening tools available that can be administered and scored in the primary care setting, such as the Beck Depression Inventory and the PHQ9. Results of these screening tools that point to a possible underlying depression or other psychological disorder necessitate a referral to a mental health professional.
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Cognitive Dysfunction
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.

Clinicians may want to refer some CFS patients to behavioral health professionals to help them problem-solve and develop specific techniques for conducting activities of daily living that have become difficult. Referral to a neuropsychologist, neurologist or psychiatrist for evaluation and testing may be necessary in severe cases to determine whether other underlying conditions may be involved. It should be noted that training to improve cognition is a highly specialized therapy and requires input of trained behavioral health clinicians.

Use caution in prescribing stimulants for cognitive problems. Mild stimulants may be helpful for some patients, but stronger stimulants can precipitate the push-crash cycle and cause relapse.

Managing Patients with CFS
While symptom management is critical to the care of patients with chronic fatigue syndrome, it is also important for clinicians to address the emotional and psychosocial consequences of CFS. Like other debilitating chronic illnesses, CFS can have a profound impact on daily life, requiring patients to make therapeutic lifestyle changes including adaptation to prevent life-altering limitations.

The overall treatment plan should acknowledge the limitations of this illness, and the patient’s emotional reactions to them. While patients are justified in their emotional response to such a devastating illness, educating them about the link between stress and symptom exacerbation is an important adjunct to validating their feelings and subsequent clinical improvement.