Common Causes of Fatigue

POTS: A Little Known Cause of Extreme Fatigue

Common Causes of Fatigue

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Everyone knows what being tired feels at the end of a long day. But some people experience fatigue so severe and so seemingly random that it’s hard to describe. If that sounds familiar, there could be more going on than daily stress.

While there are many causes of fatigue, one of them is frequently missed and misdiagnosed: postural orthostatic tachycardia syndrome (POTS). Physical medicine and neuromuscular specialist Tae Chung, M.D., answers questions about POTS and extreme fatigue as one of its symptoms.

When is fatigue considered extreme?

There is no good criteria for assessing the level of fatigue — it depends on the person. However, most people know when their tiredness is more than a lack of sleep. Some of my patients remember the exact day they got hit with fatigue so overwhelming that they knew something was wrong.

POTS is a common condition affecting an estimated one to three million Americans. Researchers don’t fully understand the causes of POTS, but it is more common in women than men and is more ly to develop in adolescents and young adults.

People with POTS experience fatigue differently. Many describe it as feeling beyond exhausted. It’s as if your energy is completely depleted. The fatigue is probably hundreds of times worse than your worst flu. People with POTS may also have trouble concentrating and thinking straight. Doing simple tasks may feel you’ve just run a marathon.

This fatigue might come and go, hitting you without warning daily, weekly or less frequently. For some people, extreme fatigue lasts for days. Others may experience periodic “attacks.” It can come on at any moment — even if you just woke up. And there is no amount of sleep or coffee that can make it go away.

What is POTS and why does it cause fatigue?

POTS is a group of symptoms resulting from dysfunction of the autonomic nervous system. This branch of the nervous system regulates functions we don’t consciously control sweating and blood circulation.

In people with POTS, more blood collects in the lower body when standing upright. The heart beats faster to pump it up to the brain, but with little success. The causes of POTS are unknown, but the problem is thought to lie in the communication breakdown between the brain and the cardiovascular system.

POTS-related fatigue is physical in nature and the mechanism behind it is not fully understood. It may have several causes, including your body working harder to move the blood.

What are other symptoms of POTS besides the extreme fatigue?

People with POTS may experience different symptoms to a different extent. These symptoms may include but are not limited to:

  • Dizziness when standing
  • Nausea and vomiting
  • Lightheadedness and fainting
  • Brain fog
  • Muscle pain and cramps
  • Headaches
  • Excessive sweating
  • Shakiness

Some people feel as though their heart is beating really fast or skipping a beat. This is called heart palpitations.

Is POTS more common in certain people?

There are no established risk factors for POTS. However, it is known to run in families, so it could have a genetic component. Researchers have also established a link between POTS and Ehlers-Danlos Syndrome (highly mobile joints). So if you have one of these conditions, you might also have the other.

A big group of those diagnosed with POTS is young women and teens. However, this doesn’t mean they are more ly to develop this condition.

Is it possible that I have POTS and was incorrectly diagnosed?

This is entirely possible. Given how common POTS symptoms are and how unfamiliar many doctors are with this condition, diagnostic mishaps happen. POTS is frequently misidentified as chronic fatigue syndrome, fibromyalgia, myofascial pain syndrome, anxiety disorder, ADHD, irritable bowel syndrome, myositis, etc.

It is also possible that you have both POTS and one of these conditions, which may complicate the diagnosis. Sometimes people with POTS are told that “it’s all in your head,” implying that the cause of their symptoms is psychological.

If you feel something is physically wrong, don’t hesitate to seek a second, and even a third or fourth opinion.

Although many people recover quickly from COVID-19, the disease caused by the coronavirus, others who recover may continue to experience symptoms for months. Researchers are still determining the cause of these extended symptoms, but some COVID-19 «long-haulers» may actually be dealing with POTS.

Problems with the autonomic nervous system can be difficult to diagnose. The standard test for POTS is the tilt table test.

During the test, you are secured to a table that tilts from being horizontal to almost a 90-degree angle. The test measures your heart’s response to switching from laying down to standing up.

Some people with POTS faint during this test, even if they rarely faint standing up.

Although the test seems straightforward, many things can interfere with it. It’s important that a POTS specialist oversees it. It’s best to work with a doctor who has diagnosed and treated patients with POTS. This could be a cardiologist, a neuromuscular specialist or another doctor.

Is POTS treatable?

While there is nothing that can make POTS go away for good, there are ways to address the symptoms. One treatment option is a diet that involves increasing your salt and water intake. This helps your body retain fluids and increase the blood volume.

The other treatment is exercise — even though it may be the last thing on your mind. Pushing through fatigue is difficult, but exercise can help you maintain healthy blood circulation.

Exercise should be prescribed and closely monitored by your doctor.

It often starts as low-intensity exercise that can be done while you are lying down, and gradually increases as your body is able to tolerate more physical activity, although each person's experience is different.

POTS treatment has to be tailored to address your specific symptoms and underlying conditions. Be wary of trying treatments you find online without consulting with your doctor. A treatment that makes one POTS patient better may make another worse.

One of the best things you can do to protect and improve your health is to stay informed. Your Health is a FREE e-newsletter that serves as your smart, simple connection to the world-class expertise of Johns Hopkins.



Common Causes of Fatigue

Fatigue is more than being tired or sleepy. People who have fatigue feel so drained that their exhaustion interrupts their daily life. Many conditions and medications can cause overwhelming tiredness. An unhealthy diet, lack of sleep and too little or too much physical activity can also lead to fatigue.

  • Overview
  • Possible Causes
  • Care and Treatment
  • When to Call the Doctor


Everyone feels tired from time to time. Fatigue is feeling severely overtired. Fatigue makes it hard to get up in the morning, go to work, do your usual activities and make it through your day.

You might have an overwhelming urge to sleep, and you may not feel refreshed after you rest or sleep.

Fatigue often occurs along with other symptoms, such as:

  • Depression and lack of desire to do the activities you once enjoyed.
  • Trouble concentrating or focusing.
  • Very low energy and motivation.
  • Nervousness, anxiety, and irritability.
  • Muscle weakness and pain.

Other signs of fatigue include:

  • Tired eyes
  • Tired legs
  • Whole-body tiredness
  • Stiff shoulders
  • Malaise (discomfort/uneasiness)
  • Boredom or lack of motivations
  • Sleepiness
  • Impatience

Many conditions, disorders, medications and lifestyle factors can cause fatigue. Fatigue can be temporary, or it can be a chronic condition (lasting six months or more). You may be able to relieve your symptoms by changing your diet, medications, exercise or sleep habits. If an underlying medical condition causes fatigue, doctors can usually treat the condition or help you manage it.

Causes of fatigue include:

  • Lifestyle habits: Poor diet, excessive alcohol, drug use, too much stress and a sedentary lifestyle can all contribute to fatigue. Jet lag commonly causes temporary fatigue (symptoms usually improve in a few days).
  • Medical conditions: Fatigue is a symptom of a wide range of diseases, disorders and deficiencies affecting various parts of the body.
  • Sleep disorders: Insomnia, sleep apnea, and narcolepsy can cause extreme exhaustion and long-term fatigue.
  • Medications and treatments: Several prescription and over-the-counter drugs, including antihistamines and blood pressure medications, can cause fatigue. Fatigue is a common side effect of bone marrow transplants, chemotherapy and treatments for a range of conditions.

What medical conditions cause fatigue?

Hundreds of conditions and disorders lead to fatigue. Some of the most common causes of fatigue include:

  • Disease and infection: Cancer, kidney disease and multiple sclerosis are just a few diseases that cause fatigue. Fatigue can also be a sign of infections such as mononucleosis, HIV and flu.
  • Mental health conditions: Fatigue from depression or anxiety may make it difficult or impossible to perform daily activities.
  • Autoimmune disorders: Fatigue is a symptom of many autoimmune diseases, including diabetes, lupus and rheumatoid arthritis.
  • Hormonal imbalances: Problems with your endocrine system (the glands in your body that make hormones) can lead to exhaustion. Hypothyroidism is a common cause of fatigue.
  • Chronic conditions: Chronic fatigue syndrome (also called CFS or myalgic encephalomyelitis) and fibromyalgia cause severe, long-lasting fatigue.
  • Heart and lung problems: Fatigue is a common symptom of cardiovascular conditions such as heart disease, postural orthostatic tachycardia syndrome (POTS), chronic obstructive pulmonary disease (COPD), emphysema and congestive heart failure.
  • Deficiencies: Anemia and other vitamin deficiencies (such as vitamin D or vitamin B12) are often responsible for fatigue. Dehydration can cause fatigue because the body needs plenty of fluids to function.
  • Weight problems and eating disorders: Anorexia, bulimia, obesity or being underweight can lead to fatigue and a range of other symptoms.

To find out what is causing your fatigue, your healthcare provider will ask questions about your lifestyle and medications and will conduct a physical examination. They might order some lab tests to test blood and urine. If you are a woman of child-bearing age, your provider will probably order a pregnancy test.

To relieve fatigue, your provider will treat (or help you manage) the condition or disorder that’s causing it. Depending on your health, your treatment plan may include a combination of medication, exercise, or therapy. If you’re taking a medication that makes you feel exhausted, talk to your healthcare provider about the risks and benefits of stopping the medication or trying another one.

How can I ease or relieve fatigue?

If a medical condition isn’t causing your fatigue, lifestyle changes may improve your symptoms. To reduce fatigue, you can:

  • Practice good sleep habits: Aim for seven to nine hours of sleep every night. Don’t drink caffeine, use electronics, or exercise right before bed. Try to go to bed and get up at the same time every day.
  • Avoid toxins: Don’t use illegal drugs, and drink alcohol in moderation, if at all.
  • Eat a healthy diet: A balanced diet and plenty of water will keep your body nourished and hydrated.
  • Manage stress: Yoga, mindfulness, meditation and regular exercise can help you relieve stress and gain more energy.
  • See your healthcare provider: Make an appointment to rule out infections, disease, illness, vitamin deficiencies and other health conditions. You should also talk to your provider about medications you’re taking to see if they are causing your symptoms.
  • Exercise often: Regular exercise is crucial for a healthy lifestyle. Though it might seem counter-intuitive, vigorous exercise can help you feel more energetic once you get used to it. But exercising too much can cause fatigue, so talk to your provider about what’s best for you.
  • Maintain a healthy weight: Talk to your healthcare provider about your ideal weight, and try to stay within that range.

It’s normal to feel tired now and then. Everyone experiences occasional, brief fatigue due to illness, sleep disturbances, travel or changes in diet or medication. But you should talk to your healthcare provider if you’re tired all the time. Call your provider if:

  • Your fatigue lasts longer than a few days
  • You’re having a hard time going to work or performing daily activities.
  • There isn’t a clear reason (such as a recent illness) for your fatigue.
  • It comes on suddenly.
  • You’re older (over age 65).
  • You’ve also been losing weight.

Fatigue can be a sign of a serious health condition. You should seek immediate medical attention if you have fatigue along with other symptoms, such as:

  • Shortness of breath or pain in your chest, arm or upper back.
  • Fast, pounding, fluttering or irregular heartbeat.
  • Headache or vision problems (especially if you’ve hit your head recently).
  • Nausea, vomiting or abdominal pain.
  • Muscle weakness.
  • Thoughts of harming yourself or others.

Last reviewed by a Cleveland Clinic medical professional on 01/20/2020.



What Are the First Signs of Fatigue? Causes & Treatment

Common Causes of Fatigue

Picture of Common Causes of Chronic Fatique Syndrome

What is the Definition of Fatigue?

Fatigue is generally defined as a feeling of lack of energy and motivation that can be physical, mental or both. Fatigue is not the same as drowsiness, but the desire to sleep may accompany fatigue.

Apathy is a feeling of indifference that may accompany fatigue or exist independently.

In addition, individuals often describe fatigue using a variety of terms including weary, tired, exhausted, malaise, listless, lack of energy and feeling run down.

How Common is Fatigue?

Fatigue is common. About 20% of Americans claim to have fatigue intense enough to interfere with living a normal life.

A physical cause has been estimated to be responsible 20% to 60% of the time, while emotional or mental causes comprise the other 40% to 80% of cases of fatigue.

Unfortunately, fatigue can occur in normal individuals that experience intense physical or mental activity (or both).

However, in contrast to fatigue that occurs with some diseases and syndromes, normal fatigue in healthy individuals is quickly relieved in a few hours to about a day when the physical or mental activity is reduced.

Also, people occasionally experience fatigue after eating (sometimes termed postprandial depression), which can be a normal response to food, especially after large meals and this may last about 30 minutes to several hours.

In addition to the many terms attributed to «fatigue,» there are further problems with the terminology used to describe fatigue. There are several «fatigue syndromes» that occasionally appear in the medical literature.

For example, Epstein-Barr chronic fatigue syndrome, post viral infection fatigue syndrome, and adrenal fatigue syndrome are among the most commonly seen.

However, many physicians do not recognize these as syndromes because the criteria used to define them as syndromes are too diffuse and many consider the associated fatigue (sometimes chronic fatigue) as either a symptom or complication of the underlying associated diseases.

However, there is a well-defined chronic fatigue syndrome recognized by specific criteria. Basically, two sets of criteria need to be met to establish a diagnosis of chronic fatigue syndrome:

1. Have severe chronic fatigue for at least six months or longer with other known medical conditions (whose manifestation includes fatigue) excluded by clinical diagnosis; and


Concurrently have four or more of the following symptoms, for post-exertional malaise, impaired memory or concentration, unrefreshing sleep, muscle pain, multi-joint, and pain without redness or swelling, tender cervical or axillary lymph nodes, sore throat, and headache. Consequently, people and their health-care professionals need to spend some time together to clearly determine whether or not the problem or symptom is truly fatigue, and if it is, any associated symptoms that may accompany the fatigue should be explored.

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Fatigue is a symptom that usually has some underlying cause. Fatigue may be described by people in different ways, and may include some combination (both mental and physical) include weakness, lack of energy, constantly tired or exhausted, lack of motivation, difficulty concentrating, and/or difficulty starting and completing tasks.

Other symptoms such as fainting or loss of consciousness (syncope), near-syncope, rapid heartbeat (palpitations), dizziness or vertigo may also be described as part of the fatigue experienced by the affected individual. The presence of these symptoms may actually help lead a health care practitioner to discover the underlying cause(s) of the fatigue.

Fibromyalgia Symptoms, Diagnosis & Treatment See Slideshow

Generally, people need to seek medical care if they experience any of the these symptoms:

  • Fatigue that comes on suddenly (not due to normal short-term physical or mental stress).
  • Fatigue that is not relieved by adequate rest, adequate sleep, or removal of stressful factors.
  • Fatigue that becomes chronic or extreme.
  • Fatigue that is accompanied by unexplained symptoms.
  • Fatigue and weakness associated with fainting or nearly fainting.

If a person experiences any of the following with or without associated fatigue, they should go to a hospital's Emergency Department:

Some additional symptoms, often associated with fatigue, should prompt an urgent visit to their doctor:

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The potential causes of fatigue are numerous. The majority of diseases known to man often list fatigue or malaise as possible associated symptoms.

This is complicated by the fact that fatigue can occur in normal healthy individuals as a normal response to physical and mental exertion.

However, normal fatigue may begin to become abnormal if it becomes chronic, extreme or prolonged fatigue; usually this occurs when a person experiences chronic or prolonged physical or mental exertion.

For example, unusually hard physical or mental exertion for one day can result in normal fatigue that may last about a day or sometimes more, depending on the exertion level, while daily unusually hard physical or mental exertion may result in prolonged fatigue (usually greater than 24 to 48 hours). This latter situation may develop into abnormal fatigue.

The causes of fatigue can be classified under several broad disease entities or lifestyle problems that have fatigue as an associated symptom. Some common causes of fatigue but that are not meant to be comprehensive include:

Metabolic/endocrine: anemia; hypothyroidism; diabetes; electrolyte abnormalities; kidney disease; liver disease; Cushing's disease

Infectious: infectious mononucleosis; hepatitis; tuberculosis; cytomegalovirus (CMV); HIV infection; influenza (flu); malaria and many other infectious diseases

Cardiac (heart) and Pulmonary (lungs): congestive heart failure; coronary artery disease; valvular heart disease; chronic obstructive pulmonary disease (COPD); asthma; arrhythmias; pneumonia

Medications: antidepressants; anti-anxiety medications; sedative medications; medication and drug withdrawal; antihistamines; steroids; some blood pressure medications

Mental Health (psychiatric): depression; anxiety; drug abuse; alcohol abuse; eating disorders (for example; bulimia; anorexia); grief and bereavement

Sleep Problems: sleep apnea; reflux esophagitis; insomnia; narcolepsy; work shift work or work shift changes; pregnancy; extra night hours at «work»

Other: cancer; rheumatology illnesses such as rheumatoid arthritis and systemic lupus; fibromyalgia; chronic fatigue syndrome; normal muscle exertion; obesity; chemotherapy and radiation therapy

For the evaluation of fatigue, the health care practitioner will take a complete history of the patient's fatigue, along with questions in regard to associated symptoms. The health care practitioner may inquire about the following activities and symptoms to determine the probable cause of the fatigue:

Quality of Life

Does the level of fatigue remain constant throughout the day? Does the fatigue get worse as the day goes on, or does the fatigue begin at the start of the day? Is there a pattern to the fatigue (time of day or time of year the holidays)? Does the fatigue occur at regular cycles? How is the person's emotional state? Does the person feel unhappiness or disappointment in life? Sleep pattern determination. How much sleep is the person getting? During what hours does the person sleep? Does the person awake rested or fatigued? How many times does the person awake during sleep? Are they able to fall back asleep? Does the person get regular exercise? Any exercise? Has the person had any new stressors in their life? Change in relationships, jobs, school, or living arrangements? What is the person's diet? Is there a high intake of coffee, sugar, or excessive amounts of food?

Associated symptoms (not all inclusive as answers may trigger other questions) fever, pain, nausea, vomiting, diarrhea, blood in urine or stool, shortness of breath, chest pain, constipation, muscle cramps or aches, easy bruising, cough, changes in thirst or urination, inability to sleep lying flat, inability to walk up more than one flight of stairs, changes in appetite, loss or gain of weight, menstrual irregularities, swollen legs, and/or mass in breast.

After obtaining the history, a physical exam will be performed, focusing on the patient's vital signs (weight, blood pressure, heart rate, temperature, breathing rate).

The doctor will observe the patient's general appearance, listen to the heart, lungs, and abdomen, and may perform a pelvic and rectal exam.

The doctor may order some of the following tests depending on the suspected underlying cause of the fatigue.

  • Blood tests provides information about an infection, anemia, or other blood abnormalities or problems with nutrition.
  • Urinalysis provides information that might point to diabetes, liver disease, or infection.
  • Chem-7 looks at 7 common substances circulating in the blood. It consists of electrolytes (sodium, potassium, chloride, and bicarbonate), waste products of metabolism cleared by normally functioning kidneys (BUN and creatinine) and the source of energy for the body's cells (glucose).
  • Thyroid function tests examine the function of thyroid gland (thyroid levels too high or too low).
  • Pregnancy test
  • Sedimentation rate test checks for chronic diseases or inflammatory conditions.
  • HIV test
  • Chest X-ray explores the possiblity infections or tumors.
  • Electrocardiogram (ECG, EKG) is an electrical recording that looks at the function of the heart.
  • CT scan of head is a A 3-dimensional X-ray of the brain to look for stroke, tumors, or other abnormalities.

The definitive diagnosis depends on discovering the underlying cause of the fatigue; this is determined by evaluating the history, the physical exam and the appropriate test results.

The treatment for fatigue depends upon the cause. Some treatments for conditions that cause fatigue include medications, antibiotics, vitamins, and exercise. Medical treatment of fatigue depends on the treatment of its underlying cause(s).

Fortunately, many causes of fatigue may be treated with medications, for example, iron supplements for anemia, medications and machines to help sleep apnea, medications to control blood sugar, medications to regulate thyroid function, antibiotics to treat infection, vitamins, and/or recommendations for dietary changes and a sensible exercise program. Again, treatment of the underlying cause(s) is the key to treatment of the symptom of fatigue.

Generally, the prognosis for fatigue is good, because many of the causes are relatively easy to treat. However, the prognosis decreases if the person has difficulty in complying with treatments or has underlying conditions (for example, advanced diabetes or COPD) that are severe and slowly progress.

What characterizes fibromyalgia? See Answer

Fatigue prevention (both physical and mental) is possible in many people. Prevention of the underlying cause in almost every situation will prevent the symptom of fatigue.

  • Manage stress and practice relaxation techniques.
  • Get exercise, but begin slowly and check with your health care practitioner before beginning any exercise program. Find a good time to exercise and develop a habit of exercise.
  • Check your medications with a health care practitioner or pharmacists to see if some medications could be responsible for fatigue.
  • Improve your diet and eat a good breakfast (whole grain cereal, fruit, milk). Add more fruits and vegetables.
  • Stop any excessive caffeine consumption.
  • Stop smoking.
  • Have sex with your spouse or partner.
  • Get enough sleep and have a good and consistent sleep routine (sleep hygiene). Go to bed at the same time every night.
  • Avoid coffee, tea, or caffeinated drinks after 6 pm.
  • Do not drink alcohol after dinner, and decrease the total amount of alcohol consumed. (Alcohol interferes with sleep patterns.)
  • People with underlying medical conditions (for example, diabetes, COPD, anxiety) can reduce symptoms of their disease, including fatigue, by working with their health care practitioners to optimize the treatment of the underlying problems.

Chronic fatigue syndrome (also called CFS) is a disorder without a known cause, although CFS may be related to a previous infection. CFS is a state of chronic fatigue that exists without other explanation for six months or more and is accompanied by cognitive difficulties (problems with short-term memory or concentration). You may have CFS if you meet the following criteria:

  • if you have severe chronic fatigue for six months or longer and all other known conditions that could cause fatigue have been excluded by your health-care provider, or
  • if you simultaneously have four or more of the following symptoms: significant problems with short-term memory or concentration, sore throat, tender lymph nodes, muscle pain, pain in several joints without swelling or redness, headaches that are different in pattern or severity from previous headaches, feeling tired and unrefreshed even after sleeping, and extreme tiredness lasting more than 24 hours after you exercise or exert yourself.

Read more about Chronic Fatigue Syndrome » REFERENCES: Centers for Disease Control and Prevention. Chronic Fatigue Syndrome (CFS).

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