How Can Fibromyalgia Be Distinguished From Chronic Fatigue?

Fibromyalgia and chronic fatigue: Widespread muscle and joint pain, feeling of continuous fatigue, sleep disturbances, headaches, memory and attention difficulties. These are some of the symptoms common to fibromyalgia and chronic fatigue syndrome

Fibromyalgia and chronic fatigue syndrome: 2 chronic diseases that are often underestimated and poorly recognised

But is it possible to distinguish between them? How are they diagnosed? And what can be done to alleviate the often disabling symptoms?

Fibromyalgia: what it is and how it manifests itself

The term fibromyalgia means pain in muscles and fibrous connective tissue structures, i.e. ligaments and tendons.

Fibromyalgia is characterised by:

  • widespread musculoskeletal pain, present for more than 3 months;
  • fatigue;
  • non-restorative sleep;
  • memory and attention difficulties,
  • rigidity and mood disorders.

Disturbance of sleep and its quality is almost the rule.

It has been hypothesised that the alteration of its cycles, especially a reduction in the deep sleep phase during which the pain threshold is normally raised, is responsible for the hypersensitivity to pain that characterises fibromyalgia.

In people already suffering from pre-existing migraine, fibromyalgia causes the intensification of intensity and frequency of headaches that can even become daily.

The link between fibromyalgia and long Covid

The ongoing Covid-19 pandemic is leading to the observation that, while most people recover after a few weeks, chronic and complex symptoms, not only respiratory, may persist or even appear at a distance in some recovered from the infection.

This condition is called long covid and a major component of it is pain.

Many convalescents, months after contracting coronavirus, complain of complex neurological symptoms, such as:

  • fatigue;
  • constant headache, often accentuated in the supine position;
  • insomnia;
  • post-exercise malaise;
  • memory problems;
  • speech problems and cognitive dysfunction;
  • muscular and neuropathic pain.


Fibromyalgia is described as a generalised non-inflammatory form of uncertain origin.

This is also why the diagnosis and clinical features of fibromyalgia have long been controversial.

The first step in diagnosis, as it is a condition with a predominantly neuropathic pain component, is to refer to a neurological specialist for an initial assessment, which may be followed by in-depth examinations if necessary.

The diagnosis is mainly based on the anamnesis and the finding of painful muscle areas.

It is also important to rule out signs of blood, rheumatological, muscular, neurological, psychological and radiological changes.

To do so, the neurologist may make use

  • of haematochemical and radiological examinations;
  • psychological or rheumatological counselling.


Once the presence of fibromyalgia is recognised, the course of treatment is not short and requires commitment to achieve significant improvements.

At present, the treatment of pain, chronic headache and other fibromyalgia symptoms is based on drugs for

  • neuropathic pain
  • severe migraine;
  • sleep disorders.

In particular, there are specific drugs against neuropathic pain, others against muscle contracture, but the gold standard is represented by certain antidepressants that also have a pain-relieving value.

It is also important not to underestimate the psychosomatic component of the disease, on which psychophysical stress and anxiety can have a negative impact, worsening the symptoms.

Chronic fatigue: how to recognise it?

Fibromyalgia shares many aspects with chronic fatigue syndrome, a problem that mainly affects young women and is often misclassified as ‘illness simulation (intentional faking of symptoms)’.

Chronic fatigue syndrome is a syndrome characterised by disabling asthenia lasting more than 6 months, of unknown origin

It is associated with a variety of symptoms, including:

  • sleep disturbances
  • sense of cognitive disturbance;
  • fatigue;
  • pain;
  • worsening of symptoms with physical activity.

Although the term chronic fatigue syndrome was first used in 1988, the disorder has been well described since the mid-1700s, but under different names: fever, neuroasthenia, chronic brucellosis, exercise syndrome.

The causes of chronic fatigue

The origin of chronic fatigue syndrome is still unknown.

No infectious, hormonal, immunological or psychiatric causes have been established. Similarly, there are no allergic markers or immunosuppression.

In the last 2 years of the pandemic, Covid 19 infection has also been hypothesised as one of the causes of this syndrome, as in part in the case of fibromyalgia.

Some people, who have recovered from Covid 19, have become carriers of chronic fatigue with persistent symptoms, some of which result from.

  • organ damage, caused by infection and/or treatment;
  • post-traumatic stress disorder.

Some researchers claim that the aetiology will prove to be multifactorial, including a predisposition to factors

  • psychosomatic;
  • genetic;
  • exposure to microbes;
  • toxins;
  • physical trauma.

In any case, it is important to emphasise the physiological legitimacy of chronic fatigue syndrome.

The symptoms: fatigue that does not alleviate even with rest

If in fibromyalgia the prevailing symptom is pain, in chronic fatigue syndrome, as the name suggests, it is asthenia.

The onset of chronic fatigue syndrome is usually abrupt: it often occurs following a psychologically or clinically stressful event.

Many patients report:

  • a viral-like illness;
  • intense fatigue;
  • fever;
  • upper respiratory tract symptoms.

The initial syndrome resolves, but triggers prolonged and severe fatigue, which interferes with daily activities and generally worsens with exertion, but is relieved little or not at all at rest.

Important general features are widespread pain and sleep disturbances, which may be associated with cognitive disturbances, such as memory problems.

How chronic fatigue is diagnosed

In the presence of symptoms that may lead one to suspect chronic fatigue syndrome, the first step is to perform an objective examination combined with laboratory tests to rule out other pathologies and any possible alternative causes of chronic fatigue syndrome.

The objective examination of the patient with chronic fatigue syndrome is normal, with no objective signs of muscle weakness, arthritis, neuropathy or organomegaly.

Laboratory investigations are also normal and generally include a blood count with formula and measurement of electrolytes, azotemia, creatinine, erythrocyte sedimentation rate and thyroid hormones.

If indicated by clinical findings, further investigations in selected patients may include radiological investigations of sleep studies and tests for adrenal insufficiency.

The diagnosis of chronic fatigue syndrome is therefore based on characteristic symptoms in patients with a normal clinical examination and normal laboratory findings.

Any abnormal physical findings or laboratory tests must be evaluated and alternative diagnoses causing these findings and/or symptoms must be ruled out.

It is important to emphasise that, as chronic fatigue syndrome sufferers generally appear healthy, friends, family members and even sometimes health professionals express scepticism about their condition and this can exacerbate the frustration and depression that patients often feel about their poorly understood disorder.


To offer effective treatment to patients with chronic fatigue syndrome, the doctor must first recognise and accept the validity of the symptoms.

Whatever the underlying causes, patients are not simulators, they are sufferers.

On the other hand, patients must accept and embrace their disability, focusing on what they can still do rather than becoming discouraged by what they cannot do.

Treatment must then be customised to the individual patient.

Therapy includes first and foremost pharmacological treatment of specific symptoms such as:

  • pain
  • sleep disorders;
  • in some cases depression.

In patients who are willing to try these and have access to the appropriate services, cognitive-behavioural therapy and a gradual exercise programme may also bring about some improvements.

Unproven or refuted treatments such as antivirals, immunosuppressants, and elimination diets should be avoided instead.

The importance of early diagnosis for both diseases

Some evidence suggests that early diagnosis, and thus early treatment, improves the prognosis in both diseases.

Most patients improve over time (years), although they often do not return to their pre-disease state and the improvement is only partial..


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