Sleep, stress & energy
Fatigue & tiredness
"I'm tired all the time." How do you turn that into something a clinician can act on?
Fatigue is common and usually not due to a serious disease, but it can point to sleep problems, anemia, thyroid disease, depression or a medicine. Describing the pattern is what gets you to the cause.
In 30 seconds
The short answer
Fatigue is a feeling of weariness, tiredness or lack of energy.1 It is common and usually not due to a serious disease, but it can be a sign of something more serious.3 When enough sleep, good food and less stress do not relieve it, it should be checked by a health care provider.4 The causes they look for first are ordinary and testable.612
- Fatigue is not sleepiness. Drowsiness is needing to sleep; fatigue is a lack of energy and motivation.2 Say which one you mean.
- The common causes are checkable — sleep disorders, anemia, thyroid problems, depression and medicines.68
- Your medicine list matters. Allergy pills, blood pressure medicines, sleeping pills and steroids can all cause fatigue.8
- Worse for days after effort is a specific signal. It is the hallmark of ME/CFS, a biological illness.2930
Three complaints that sound alike
Three complaints that sound alike
Saying which one you have changes what gets checked.
Fatigue
Turning "tired all the time" into something useful
An illustration of how to prepare, based on what MedlinePlus says your provider will ask.
Notice the pattern
A fatigue diary shows when you feel more tired and when you have more energy.13
Note sleep and effort
Your provider will ask about sleep, daily activities, appetite and exercise.14
Bring your medicine list
Several common medicines can cause fatigue.8
Get checked
Blood, kidney, liver and thyroid tests may be ordered.12
What the research says
- Experts recommend 7 to 9 hours of sleep a night for adults.16 Adults who sleep less than 7 hours may have more health issues.17
- Sleep apnea can cause loud snoring and breathing that starts and stops — and you may not know until someone tells you.18
- Long-lasting diseases such as diabetes, COPD, and heart, liver, kidney and thyroid diseases can cause fatigue, as can depression and anxiety.7
- Stimulants, including caffeine, are not effective treatments for fatigue, and sedatives tend to make it worse.10
- Vitamin B12 deficiency, which can make you tired or weak, affects between 3% and 43% of older adults.2527
- Regular activity, better sleep habits, not smoking, managing stress and a healthy diet can help you feel less tired.15
Common checkable causes
| Possible cause | Clues worth mentioning | How it is usually checked |
|---|---|---|
| Sleep apnea | Loud snoring, breathing that stops and starts, gasping; daytime sleepiness.1819 | A sleep study.20 |
| Anemia | Weakness, paleness, tiredness, shortness of breath.21 | Blood tests.12 |
| Underactive thyroid | Fatigue, weight gain, trouble tolerating cold.22 | Thyroid blood tests.1224 |
| Medicines | Allergy antihistamines, blood pressure medicines, sleeping pills, steroids, water pills.8 | A medicine review. Never stop a medicine on your own.9 |
| Depression or grief | Feeling sad or depressed is a reason to book a visit.6 | A conversation with your clinician.11 |
| Vitamin B12 deficiency | Feeling tired or weak; long-term metformin.2526 | A blood test of your B12 level.27 |
Fatigue and weight gain are common and do not necessarily mean a thyroid problem — which is why testing, not guessing, settles it.23
When rest does not help: ME/CFS
Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a biological illness that affects many body parts.29 It is less common than the causes above, but often missed.
Adults who had ME/CFS, 2021–2022
Percent of U.S. adults, by sex and by age, from the National Health Interview Survey.
Survey estimates for U.S. adults, not a measurement of any patient or of a ProperHealth or Clarkson service.
- The hallmark is post-exertional malaise: symptoms get worse after physical or mental activity.30
- Up to 3.3 million people in the U.S. may have it; more than 9 in 10 are undiagnosed.31
- There is no specific test, which makes it difficult to diagnose.38
- There is no cure, but symptoms can be managed — including by avoiding "push and crash".3233
From the Dr. Majid Ali archive
A historical perspective
“This is an age of chronic fatigue.”— Dr. Majid Ali, 2015-01-22Dr. Ali took chronic fatigue seriously at a time when much of medicine did not. He called fatigued patients "human canaries" — early signals, not people with nothing wrong — and treated the overlap of fatigue and fibromyalgia as real.
Current guidance is consistent with that stance: CDC describes ME/CFS as a biological illness.29 The sources used here do not support his explanations for it.
Where ProperHealth stops. The sources used here do not support his oxidative or "dysox" mechanism or his remedy protocols, and his advice to stop looking for a diagnosis runs against current guidance. Fatigue that rest does not fix should be evaluated, starting with the common causes.46
What to do next
Keep a two-week fatigue diary
Note when you feel more tired and when you have more energy.13 Add bedtime, wake time and how often you wake.
Ask someone if you snore
Sleep apnea symptoms often go unnoticed until someone tells you.18
Write down what effort does to you
Better after rest, or worse for days afterwards? Worsening after effort is a specific signal.30
Bring your full medicine list
Several common medicines can cause fatigue.8 A pharmacist can point out which ones to ask about.
Skip the energy shots for now
Stimulants, including caffeine, are not effective treatments for fatigue.10 Spend the effort on getting checked.
Medicines, supplements and safety
A pharmacist can identify medicines likely to be contributing, check timing and interactions, and help you prepare questions for your prescriber. A pharmacist does not diagnose the cause of fatigue or order blood tests.
- Medicines are a common, checkable cause. Allergy antihistamines, blood pressure medicines, sleeping pills, steroids and water pills can cause drowsiness or fatigue.8 Some antidepressants can too.9
- Do not stop a medicine on your own. Talk to your provider first; they may adjust the dose or switch you.9
- Caffeine and stimulants do not fix fatigue, and can make it worse when stopped. Sedatives also tend to worsen fatigue.10
- Metformin and vitamin B12. Metformin might lower B12 levels,26 and B12 deficiency can make you tired or weak.25 Worth asking about if you have taken it for a long time.
- Be wary of cure claims. Some treatments promoted as cures for ME/CFS are unproven, often costly, and could be dangerous.34
Compared
Conventional and integrative care, compared
How fatigue is worked up rather than medicated, which medicines cause it, what the common causes are, and where lifestyle and ME/CFS management stand.
What conventional treatment does
- Fatigue is evaluated, not medicated: at the visit you will be asked about your medical history, your fatigue, and your lifestyle, habits and feelings,11 and tests may include blood tests for anemia, diabetes, inflammation and infection, plus kidney, liver and thyroid function.12 A blood test might confirm an underactive thyroid,24 a sleep study may be needed to diagnose sleep apnea,20 and a doctor can test your B12 level.27
- Treatment follows the cause. For ME/CFS there is no cure or approved treatment, but some symptoms can be treated or managed, and learning new ways to manage activity can help.32
Limits and adverse effects
- Certain medicines cause drowsiness or fatigue — allergy antihistamines, blood pressure medicines, sleeping pills, steroids and water pills8 — and some antidepressants may cause or worsen it; do not stop or change any medicine without first talking to your provider.9 Stimulants, including caffeine, are not effective treatments for fatigue and can make it worse when stopped; sedatives also tend to worsen it.10
- Metformin might reduce vitamin B12 absorption and lower B12 levels.26
What contributes to the condition
- Possible causes include anemia, depression or grief, sleep disorders such as obstructive sleep apnea, and an underactive or overactive thyroid.6 Long-lasting diseases — diabetes, COPD, and heart, liver, kidney and thyroid disease — can cause fatigue, as can depression and anxiety.7 Adults who sleep less than 7 hours a night may have more health issues.17
- Fatigue and weight gain are common and do not necessarily mean a thyroid problem.23 ME/CFS fatigue is different: it lasts a long time, does not get better with rest, and limits ordinary daily activities,28 with symptoms worsening after any physical or mental activity — post-exertional malaise.30 Up to 3.3 million people in the U.S. may have it, more than 9 in 10 undiagnosed.31
Integrative and naturopathic approaches, by evidence
Evidence levels: EstablishedEmergingHypothesisNot supported
- Established
Lifestyle changes that can help: regular physical activity, better sleep habits, stopping smoking, managing stress, a healthy diet and avoiding alcohol.15 Experts recommend 7 to 9 hours of sleep a night.16 A fatigue diary can help you find patterns.13
- Emerging
For ME/CFS, avoiding "push and crash" — feeling better, doing too much, then getting worse again — is the management approach MedlinePlus describes.33
- Not supported
Some treatments promoted as cures for ME/CFS are unproven, often costly, and could be dangerous.34
Fatigue that enough sleep, good nutrition and a low-stress environment do not relieve should be evaluated by a provider;4 if you have been feeling tired for weeks, book that visit.5
When to get help now
Each warning sign cites the official guidance behind it. The wording still needs pharmacist sign-off.
- New confusion, severe headache, chest pain, or weakness on one side — call 911.3940
- Thoughts of harming yourself — call or text 988 in the U.S., or call 911 if you are in danger.4142
- Falling asleep while driving, at work or mid-conversation — do not drive while drowsy, and talk to your provider.43
- Breathlessness at rest, fainting, or new ankle swelling with fatigue — contact your provider right away.444546
- Fatigue with unexplained weight loss, fever or night sweats, or unusual bruising or bleeding — book an appointment promptly.4748
- Loud snoring with pauses in breathing, or waking up gasping — ask for a sleep assessment.49