Treating Post-Exertional Malaise in Chronic Fatigue Syndrome

Post-exertional malaise (PEM) is a key symptom of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). It causes a spike in symptoms and a massive energy crash after what other people would consider minor exertion.

Woman tired after cleaning home

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PEM is one of the most debilitating symptoms of ME/CFS. As of yet, no drugs specifically treat it. But you can use strategies to help manage it, including pacing your activity and taming stress.

This article walks you through practical approaches that may help you manage PEM. It'll also looks at the controversy surrounding exercise for PEM and ME/CFS.

Managing Your ME/CFS

Improving PEM often involves taking a step back and making sure that your ME/CFS is well-managed in general.

ME/CFS treatments not directly aimed at PEM may help with this symptom by lessening the overall severity and burden of your disease. There are a lot of treatment options to explore with your healthcare provider.

Be sure to discuss all treatments with your healthcare team to ensure your choices are safe and likely to be effective.

You'll need to find a unique combination of treatments and management strategies tailored to your specific symptoms and situation. This may take some trial and error.

Rest, Pacing, and Lifestyle Changes

It's better to prevent PEM than deal with symptoms. A 2020 study quotes many participants as saying complete rest is the only thing that helps alleviate their PEM once it starts.

Preventing PEM often means changing the way you do things. Basically, you have to gear down your activity level to what your body can handle.

That may mean giving up activities you love and paring your life down to the bare essentials. It's a difficult process, but it can make a huge difference in your quality of life.

Some people call this "living within the energy envelope." The most popular explanation in the patient community is an essay called "The Spoon Theory" by Christine Miserandino.

A 2012 consensus document on ME/CFS showed people with the disease consistently rated pacing as one of the most helpful options for managing their symptoms.

The pacing techniques that work best may be very personal to you, but some worth trying include:

  • Alternating brief bouts of activity with rest
  • Tackling higher priority tasks first
  • Listening to your body and taking a break when it's asking for one

Don't Make Comparisons

Your ideal activity level is unique. Don't measure yourself against other people, even others with ME/CFS. Learn your own body's limits and stick to them.

Stress Management

ME/CFS is believed to be worsened by stress. But a connection to stress does not mean ME/CFS is a psychological illness. Stress has myriad physiological causes and effects. One that's received a lot of attention from ME/CFS researchers is the stress hormone cortisol.

In a 2014 study on stress, researchers concluded that stress management had an indirect effect on PEM. Essentially, those with better stress management had better morning cortisol levels. Those cortisol levels were linked to less severe PEM.

Managing your stress may help you reduce post-exertional malaise and other symptoms. Some ways to approach stress management include:

  • Learning to say "no" and limiting your commitments
  • Deep breathing for relaxation
  • Meditation and mindfulness techniques
  • Yoga and Tai Chi, if you're able to tolerate the activity without triggering PEM
  • Delegating or asking for help with stressful tasks

If stress and anxiety are a big problem for you, talk to your healthcare provider about what might help. This may include anti-anxiety medications or mental health counseling.

Nutritional Supplements

Researchers haven't done much work specifically on supplements for PEM. But some healthcare providers make recommendations based on known functions of supplements, abnormalities associated with PEM, and anecdotal information from people with the condition.

Supplements sometimes suggested include:

However, these have only been studied for either ME/CFS in general or for related fatigue. Researchers don't yet know whether they're effective against PEM specifically.

Be aware of side effects and possible negative interactions of supplements. It's important to talk to your healthcare provider and pharmacist about all the supplements you take.

Exercise: A Controversial Approach

You're probably asking, "How can exercise help when it's the cause of PEM in the first place?" That's fair, and the topic is actually a controversial one in the ME/CFS space.

A segment of the medical community advocates for a treatment called graduated exercise therapy (GET) as a first-line treatment for ME/CFS. GET involves starting with small amounts of exertion and gradually increasing it. The goal is to build up a tolerance to exercise.

Supporters point to research suggesting that GET is beneficial. But some research suggests it is actually harmful to people with ME/CFS.

Differing opinions on this aside, most agree that people with ME/CFS need to get some exercise. Muscle weakness and inactivity make you even less able to handle exertion. They also increase other symptoms like pain and stiffness, as well as your risk of other illnesses.

However, the fact is that if you have ME/CFS, you can't handle therapeutic exercise like other people can. You must know your limits and stick to them strictly.

Some people with ME/CFS turn to physical therapy, but with mixed results. It's important your therapist is familiar with your inherent restrictions so they don't push you too far.


Better management of your ME/CFS overall may help improve your post-exertional malaise. Speak to your healthcare provider if you feel your treatment plan isn't as effective as you need it to be.

Rest may be the best treatment for PEM specifically. Pacing yourself and making lifestyle changes may require some sacrifices, but the pros of doing so will likely outweigh the cons.

Stress management may indirectly improve PEM by lowering the severity of your condition. And while research is lacking, some find nutritional supplements (CoQ10, NADH, probiotics) to be helpful.

Exercise is a controversial approach to treating ME/CFS and PEM, but some activity is generally recommended.

A Word From Verywell

ME/CFS can be debilitating and PEM is a key reason why. The scarcity of research on the disease and its major symptoms can be frustrating and leave you not knowing what to do.

Keep in mind that many people with ME/CFS have found the right set of treatments for them. Work with your healthcare provider, try a variety of approaches, and stick with what works—even if just a little.

If you can find several treatments and management strategies that all help some, eventually they can add up to a big improvement.

14 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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Additional Reading

By Adrienne Dellwo
Adrienne Dellwo is an experienced journalist who was diagnosed with fibromyalgia and has written extensively on the topic.