Fatigue in Fibromyalgia
Causes & Treatments
Fatigue in fibromyalgia is far more than being tired. Rest does not make it go away, and even simple daily tasks can feel overwhelming. Sometimes it can feel like hitting a brick wall. This exhaustion may affect your body, thinking, motivation, and ability to function. Sleep and stress management may help, but they rarely solve the problem on their own.
Despite how disabling fibromyalgia fatigue can be, relatively few studies have focused on what causes it or how best to treat it. In this article, three physicians share their fatigue treatment strategies.
The Reality of Fibromyalgia Fatigue
A research team in Spain described fibromyalgia fatigue with four words: unpredictable, uncontrollable, unseen, and unintelligible—the “4 U’s.”1 These words capture why this symptom can feel so frustrating.
Because the fatigue is unpredictable, you may second-guess whether you can commit to plans. Because it is uncontrollable, even days of rest may not restore your energy. Because it is unseen, others may not recognize how much effort daily life requires. And because it is unintelligible, people who have never felt this level of exhaustion may not understand why you cannot simply push through it.
Your body may feel heavy, your muscles weak, and ordinary tasks may require more effort than you have available. At times, the weight of fatigue can feel crushing. Mental exhaustion can also make it harder to think clearly, make decisions, or get motivated. It can feel as though your mind and body are stuck in a thick fog.
Causes of Fatigue
Although your muscles may feel powerless, fibromyalgia fatigue appears to begin mostly in the central nervous system. Changes in brain function, sleep, body rhythms, and muscle efficiency may all contribute. Together, these changes can make everyday activity feel far more demanding than it should.
Brain Function – Brain imaging studies suggest that changes in the thalamus may contribute to fatigue severity in fibromyalgia.² The thalamus helps filter sensory information. When this system works less efficiently, the brain may become overloaded, intensifying both fatigue and pain. Another study linked fatigue to activation of microglia, immune cells in the brain that may play a role in inflammation.³
Sensory Pathways – Your muscles send sensory messages through the spinal cord to the brain, which then sends instructions back to your muscles. In fibromyalgia, this communication loop may not work normally.⁴ As a result, ordinary activity may feel unusually strenuous, making a walk through the grocery store feel like you ran a marathon.
Sleep Disruption – Many people with fibromyalgia have light, unrefreshing sleep. Restless legs syndrome and obstructive sleep apnea are also common. Treating these sleep problems can help, but better sleep alone may not fully restore your energy.
Body Rhythm Shifts – Melatonin helps set your sleep-wake cycle. Usually, it rises at bedtime and drops by morning. In fibromyalgia, this rhythm may shift, creating a jet-lagged feeling that adds to fatigue.⁵ See Hormonal Fatigue for more details.
Muscle Fatigue – Nervous system changes appear to drive much of the exhaustion, but your muscles may also work inefficiently.⁶ They may not contract smoothly or fully relax between contractions, causing them to burn through more fuel. Myofascial trigger points, or painful muscle knots, may add to this problem. See Muscle Fatigue & Stiffness for details.
Medication Strategies
Medication trials for fibromyalgia rarely focus on fatigue, but several drugs may help improve energy, alertness, sleep, or pain-related fatigue. Because fatigue also occurs in conditions such as cancer, long COVID, and ME/CFS, Matthias Karst, M.D., says treatment approaches may overlap. Anna Woodbury, M.D., agrees that physicians often need to draw from studies of other fatigue-related conditions.
Pain control can also improve energy. “Fatigue is highly correlated with pain,” says Amir Minerbi, M.D., Ph.D. “Improvements in fatigue often coincide with reduced pain severity.” Still, he cautions that “fatigue is often overlooked when we focus on pain.”
“Methylphenidate has the most profound and obvious effect in my fibromyalgia patients,” says Woodbury. The change can be like day and night. Minerbi also prescribes stimulants like methylphenidate. In addition, he sometimes finds modafinil or armodafinil beneficial, and they are less regulated.
“Independently of the indication for depression,” says Karst, “I have good experience with buproprion.” Other activating antidepressants that he finds helpful are duloxetine, Savella, and fluvoxamine. The first two both raise serotonin and norepinephrine, and it is the impact on norepinephrine that is activating. On the other hand, fluvoxamine only increases serotonin, but the drug possesses a unique anti-inflammatory property to ease fatigue.
The medication options below may help improve energy, alertness, sleep, or pain-related fatigue. See the medication table for dosing and common side effects. If side effects occur, ask your doctor whether trying a lower dose might help.
Energizing Meds
Stimulants – Methylphenidate and Adderall increase dopamine and norepinephrine, two activating brain chemicals. They may improve alertness and, for some patients, brain fog. However, these Schedule II drugs are tightly regulated. In one study, stimulants eased brain fog in one out of three patients and reduced generalized fatigue in 20 percent.⁷
Modafinil/armodafinil – These wakefulness-promoting drugs were developed for narcolepsy. They increase dopamine and norepinephrine but target fewer brain centers than traditional stimulants. They have low addiction potential and are less regulated Schedule IV drugs. Like stimulants, they may improve cognition more than overall fatigue.⁸
Activating Antidepressants – Bupropion increases norepinephrine and dopamine, but not as strongly as stimulants or modafinil-type medications. The 12-hour “SR” version is less likely to disrupt sleep. Savella (milnacipran) and duloxetine increase both serotonin and norepinephrine. Savella has a stronger norepinephrine effect and may be more likely than duloxetine to reduce fatigue. Fluvoxamine may also ease exhaustion by calming immune activity. These medications are not regulated drugs.
Sleep Meds – “Pregabalin helps some of my fibromyalgia patients with sleep when taken in the evening, which can subsequently improve fatigue,” says Woodbury. Minerbi prescribes gabapentin as an alternative but cautions that daytime use may worsen fatigue. Both medications treat restless legs syndrome and may help offset the lingering effects of daytime energizers. See Sleep Treatments for other helpful agents.
Low-Dose Naltrexone (LDN) – “Some of my patients have success with LDN for easing fatigue,” says Karst. Researchers think LDN may reduce activation of microglia, immune cells in the brain that may contribute to fatigue.
Alternative Treatments
Alternative treatments for fibromyalgia fatigue may help you conserve energy, sleep better, or feel more alert. Some cost little or nothing, while others can be expensive.
Lifestyle Changes – Move in ways that reduce strain and save energy. For example, avoid working with your arms extended, use support pillows when needed, and remember to breathe slowly and fully. On low-energy days, try to stand and move briefly each hour. Free stress-reduction tools, such as PainGuide, may also help. Most importantly, pace yourself and avoid overdoing it on better days.
Nutrition – Avoid sugar “pick-me-ups” because they can lead to an energy crash. Instead, eat protein throughout the day, drink plenty of water, and limit processed foods and simple carbohydrates.
Supplements – Karst recommends two supplements for stamina: ginseng and acetyl-L-carnitine. Woodbury suggests several sleep aids that may indirectly ease fatigue, including melatonin, valerian, and kava. Although you do not need a prescription for supplements, ask your doctor before taking them because they can cause side effects or interact with medications.
Cranial Electrical Stimulation (CES) – An Alpha-Stim CES device is an FDA-cleared therapy for insomnia and anxiety. The device may rock you to sleep but it will set you back $840 unless you are a Veteran. Fortunately, the side effects are mild.
Massage Therapy – Massage may ease painful muscle knots and improve circulation. In a one-month study of fibromyalgia patients, it improved fatigue, sleep, and muscle discomfort.⁹ Short treatments focused on the neck and shoulders may be enough.
Acupuncture – Woodbury recommends an invigorating style of acupuncture called Mega Mu Shu. If you are interested in acupuncture, check whether your health insurance covers it.
Other Treatable Causes
Do not assume all fatigue comes from fibromyalgia. “It’s very important to check for detectable factors that cause fatigue, such as anemia, depression, or a pain flare-up,” says Karst. Treating these problems may improve your energy, even if fibromyalgia remains part of the picture.
Karst also checks for the MTHFR polymorphism, a genetic variant that can affect folate, or vitamin B9, processing. This variant may worsen fatigue and cognition. Iron can treat anemia, while B vitamins plus methylfolate may help if MTHFR-related folate problems are present.
Nutritional deficiencies can also add to exhaustion. “Low vitamin D contributes to musculoskeletal pain, depression, fatigue, and colon cancer,” says Woodbury. Low magnesium stores may also worsen muscle weakness and fatigue, but blood levels may not reflect your true magnesium status. For this reason, Woodbury says a trial of 500 mg per day may be worth discussing with your doctor. She adds, “Some of my patients like using magnesium sprays over their muscles.”
The key point is this: fibromyalgia can cause severe fatigue, but other treatable problems may make it worse. Identifying and treating these factors may help you regain some energy.
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References Fatigue in Fibromyalgia
- Velsaco-Furlong L, et al. Int J Environ Res Public Heath 17:6224, 2020. Free Report
- Liu HY, et al. Clin Exp Rheum 41:1230-1237, 2023. Free Report
- Albrecht DS, et al. Brain Behav Immun 75:72-83, 2019. Free Report
- Zambolin F, et al. PLOS ONE 17(10):e0276009, 2022. Free Report
- Caumo W, et al. J Pain Res 12:545-556, 2019. Free Report
- Ibarra JM, Ge HY, et al. J Pain 12(12):1282-88, 2011. Free Report
- Blockmans D, Persoons P. Acta Clinica Belgica 71(6):407-414, 2016. Abstract
- Garg H, et al. BMJ Case Rep 14:e240283, 2021. Free Report
- Nadal-Nicolas Y, et al. Int J Environ Public Health 17:4611, 2021. Free Report