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Understanding chronic fatigue syndrome, migraines and 'brain fog'

Everyone knows what it feels like to be tired. But what if you seem to always be tired, extremely tired, day after day, even after a good night's sleep? Could it be that you have chronic fatigue syndrome?

Dr. Nancy Klimas, the director of the Institute for Neuro-Immune Medicine at Nova Southeastern University, specializes in myalgic encephalomyelitis – chronic fatigue syndrome. She explained the debilitating condition, which commonly results in migraines, "brain fog" and other crippling conditions.

Chronic fatigue syndrome patients suffer an ongoing feeling of exhaustion.

"The key feature of CFS is the relapse that happens after a person exerts (energy)," Klimas said. "That's a very weird symptom. It doesn't happen in very many illnesses and it only happens in neuro-inflammatory illnesses."

Multiple sclerosis and myasthenia gravis are other illnesses where exercise can "drive (a person) into a relapse," Klimas said. "It is a neuro-immune disease."

Some of the key biologic features of ME/CFS are neuro inflammation and oxidative stress in the brain and body, she said.

In clinical terms, Klimas said, "It's a brain disease with systemic inflammation."

It is the sector that features symptoms such as headaches and cognitive problems, like "brain fog," which is caused by the patient exercising their brain and running out of capacity.

Women are more commonly affected than men. Klimas said that the average age people show chronic fatigue syndrome is when they are in their early 30s. She found that more than half of the individuals she treated developed it after battling a viral condition. One of the more common viruses that can induce chronic fatigue syndrome is Epstein-Barr Syndrome.

While some experts said the exact cause of the condition is unknown, experts also said they find links to environmental and genetic factors as well.

A large number of migraine sufferers have made their way into Klimas' chronic illness clinic. As a result, she said that patients who have chronic fatigue syndrome and also suffer from migraine headaches, which is not unusual, can have "better days and worse days, but not fabulous days."

Those with chronic fatigue must manage their energy and not overstimulate their system or they will pay the price.

In comparison, Klimas said individuals who suffer with migraines alone, not chronic fatigue syndrome, are much more fortunate.

"I have found that a lot of migraine-only patients, between their episodes of migraine, are very, very healthy," Klimas said. "They are functional. They can exercise."

The common denominator between chronic fatigue syndrome and migraines seems to be rooted in the fact that they are both neuro-inflammatory conditions. Migraine sufferers are very familiar with how their neuro-inflammatory symptoms causes light to bother their eyes in photophobia. They can have trouble sleeping and experience long periods of fatigue.

"It's one of the consequences of severe periods of pain," Klimas said. "Pain is a terrible thing. It can absolutely cause fatigue. (With migraines), you have to break the headache cycle as well as the fatigue cycle. They interplay a lot."

With her chronic fatigue syndrome patients, Klimas said migraines add an additional level of pain to their condition and "you better deal with the pain because they are not going to get out of the cycle unless you deal with the migraine."

With chronic fatigue syndrome patients, Klimas described them as "individuals who have an energy system that is like a bucket less than half-full."

She said as those patients go through their day, their "bucket" slowly empties until their energy is fully depleted.

"(They) have to wait for it to fill back up again," Klimas said. "Or, (they) can go about (their) day, tapping a little bit of (their) reserve and not emptying the bucket."

This method allows the patient to get through the day easier. Essentially, it's a strategy of using a little bit of energy at a time and taking breaks, she said.

"You have to fill the 'bucket' back up; if you let it go to the bottom, you're done," Klimas said.

Fatigue resulting from pain and debilitating health conditions doesn't just affect the body, Klimas said. Many people are finding they are experiencing a condition referred to as "brain fog," also known as cognitive exhaustion.

"Cognitive energy is a different thing," Klimas said. "Your brain is making more energy and using more energy than any of your muscles. You've got more mitochondria (energy production units) per cell in your brain by a hundredfold than in your muscles. Using a lot of this energy makes more oxidative stress. If you are using your brain, you need little mental breaks as well. You have to deliver oxygen and glucose, but also take away the oxidative stress stuff (lactic acid).

"Oxidative stress in the brain and body are vicious cycles, they drive each other. The more oxidative stress, the more inflammation, they go push-push. Those two are circular," she said.

The best and easiest way to help alleviate cognitive exhaustion?

"The most effective way to rest your brain is to be flat," Klimas said. "When you're upright, more blood flow goes to the legs and feet. When you're lying flat, you're actually getting more blood flow to your brain than when you are upright."

Thus, rest breaks pertain both to the body and the mind.

"Take mental breaks; lie down for a minute; then come back and function again," Klimas said. "Brain fog is basically driving the brain into higher levels of inflammation and oxidative stress."

Klimas said there is "a lot of fibromyalgia associated with chronic fatigue syndrome."

She estimated between 60% and 70% of patients have both conditions.

In addition to pain and fibromyalgia, autonomic dysfunction is a common systemic symptom of chronic fatigue syndrome. Autonomic dysfunction includes irritable bowel syndrome, racing heart, blood pressure fluctuations – especially drops – migraines and a host of other things.

When dealing with chronic illness, it is easy for patients to feel overwhelmed, but Klimas shared some advice for patients.

"Learn to coexist with (your) illness," she said. "Give it the respect it deserves, but carry on. Find a way to carry on.

"Psychologists call it 'positive denial,' The positive side is 'I've learned to adapt.' 'I take my medicine, but I'm not allowing (the) disease to drag me down into a black pit of despair.' I think positive denial is a great thing to try and achieve," Klimas said.

In addition to being the director of the Institute for Neuro-Immune Medicine at Nova Southeastern University; Dr. Nancy Klimas is the director of Clinical Immunology Research at Miami Veterans Affairs Medical Center; a member of the VA Research Advisory Committee for Gulf War Illness and the immediate past president of the Internal Association for chronic fatigue syndrome and myalgic encephalomyelitis.

Shelby Ramsey is the author of the blog,, which also features interviews with patients and medical experts.


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