Fatigue is the common symptom in multiple sclerosis, reported by over 80% of patients. Along with cognitive impairment, it is the most important reason that MS patients stop working. Why does it happen and how can it be treated?

There are three forms of fatigue;

1. “Normal” fatigue affects all of us.
2. “Secondary” fatigue is caused by, say, lack of sleep, depression, pain, fever, and dehydration. Some MS medications used to treat spasticity, pain, depression, urinary symptoms, sleep, and anxiety can cause fatigue.
3. “Primary” fatigue may be unique to MS and other autoimmune disorders. It is described as overwhelming, is not sleepiness or deconditioning and does not improve with rest.

So, what causes primary fatigue? Importantly, new or worsening severe fatigue for which no cause be found is often a relapse and should not be ignored as it indicates inadequate control of the disease. In fact, patients prone to fatigue may have distinct structural and functional MRI abnormalities in certain areas of the brain. Be careful not to blame patients for being fatigued.

Treating fatigue in MS is a challenge. Look carefully at every medication. Focus on depression, stress, sleep, and pain. MS symptoms come in “clusters.” Be sure there is not ongoing “subclinical” disease activity that could be controlled with a different disease-modifying-therapy. Encourage exercising to tolerance. Anything is better than nothing. Walk to the mailbox. Use cooling vests. Try medications such as amantadine, modafinil, di-fampridine, or even amphetamines. But don’t give up!

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