8 Steps to Managing Fatigue

People with vestibular disorders commonly report fatigue as one of their symptoms. Follow this step-by-step guide to learn how to manage your fatigue.

Step 1: Understand Fatigue

Fatigue is a general term that describes a wide variety of symptoms, all having to do with feeling less energetic and alert than you’d like to be. For some people, fatigue may mean having less endurance for daily or new activities. For others, it may mean feeling generally unwell or low energy. It may also mean having symptoms like “brain fog” in which normal activities take more effort than they used to.

Why Are People with Vestibular Disorders Vulnerable to Fatigue?

To understand why vestibular disorders so often lead to symptoms of fatigue, it’s helpful to understand how the vestibular system works. When no disorder is present, the eyes, ears and sense of touch (proprioception) collect a huge amount of information from the outside world. They send this information to the brain, which sifts through the information to pull out what’s important. The brain puts all the important information together (integration) and sends signals to the body telling it how to respond.

Central Nervous System Is Working Harder

When a vestibular disorder occurs, one of the steps in that process is not working correctly. In some disorders affecting the sensory systems (such as Meniere’s, BPPV and vestibular neuritis), the senses are sending incorrect or confusing information to the brain. Other disorders affect the central nervous system itself (such as vestibular migraine and PPPD). In those instances, the senses are sending good information but the brain itself is not processing it correctly. In both cases, the brain is forced to do more work to sift through the information it’s getting from the senses to filter out the noise. People with vestibular disorders have to concentrate harder and use more energy just to figure out where they are in space, leaving them with less energy to perform daily activities.

Chronic Stress

Another factor that can affect people’s energy levels is the general state of their central nervous system (brain and spinal cord). When someone is suffering from repeated or prolonged episodes of stress, which is certainly the case for many people with vertigo, dizziness and balance issues, the body enters a state of chronic stress. Chemical changes within the central nervous system in response to chronic stress make the body less sensitive to hormones help you feel alert. This leads to feelings of fatigue and dullness.

Emotional Responses and Social Factors

Finally, vestibular disorders take an emotional toll on many people. Since vestibular disorders are often a chronic condition, sufferers often struggle with feelings of guilt or loss when they are not able to perform the same way they did before they started having symptoms. That can be compounded by the reaction of other people. Since vestibular disorders are “invisible,” people with vestibular disorders may perceive that others are judging them for their reduced energy levels or capacity for activities.

Step 2: Create a Forward-Thinking Mindset

Are you living in the past and stuck thinking about what you used to be able to do? You might feel trapped there, which can further drain your energy. Using cognitive-behavioral tools to help you focus on the present instead of the past can be very helpful in helping you manage your fatigue.

Use Empowering Words

One tool that is simple to use is to change the way you talk about your fatigue- either internally or to others. When we make negative statements, we also reinforce our negative feelings and beliefs. Words that can make a difference in how you approach your fatigue are “yet,” and “when.” Tack “yet” on to statements that you make to yourself and others about your fatigue. For example, “I don’t have the energy to play with my kids/grandkids- yet.” Instead of, “I haven’t found a way to manage my fatigue and I never will,” practice saying, “I haven’t found a way to manage my fatigue yet.” And instead of saying things like, “If I ever have the energy to go dancing,” practice saying, “When I have the energy to go dancing.”

Practice Self Compassion

Think of your kindest and most compassionate friend or family member. Imagine the most empathetic things that he or she would say to you when you’re not feeling well, and write them down. Then, at times when you’re feeling down about your fatigue, read those statements out loud to yourself. It might feel odd at first, but being compassionate to yourself is an evidence-based way of managing many different negative emotions and helping yourself change your mindset.
If you want to learn more about self compassion and learn how to do it, take a look at “The Self Compassion Workbook” by Kristin Neff.

Get Professional Help

Some people will benefit from professional guidance from a mental health professional in learning how to move forward. Research shows that a trained professional with experience in cognitive-behavioral therapy and chronic conditions may help you manage fatigue and other symptoms from your vestibular disorder.

Step 3: Know Yourself, Know Your Triggers

For many people with vestibular disorders, fatigue is an ever-present companion. For others, fatigue only occurs after a vertigo attack. To manage your fatigue successfully, you have to know yourself, what seems to trigger your fatigue, and your energy level patterns. That will enable you to make a plan of action. If you haven’t already, it’s a good idea to keep a diary for a few weeks. While you are journaling, keep track of what your energy levels look like day-to-day. Do your energy levels fluctuate (go up and down)? What can you identify about patterns in your fatigue?

Three Big Categories of Contributors to Fatigue

This list is to get you started thinking about what may be contributing to your experience of fatigue. Some of your triggers or contributors may fall into multiple categories- and that is ok. Once you have logged your fatigue, see if you can identify and make a list of the factors that most likely contribute to your fatigue. You might only have one, or you may have many. There is no right or wrong list of triggers. But most people find that even if the biggest contributor is the most obvious (e.g. vestibular attacks), they are also affected to a lesser degree by other triggers (e.g. stress and feeling isolated).

Lifestyle & Biological Contributors

These are factors that relate to your body’s daily physical functions. Examples include:

• Vestibular attacks such as migraines, Meniere’s episodes or BPPV
• Inadequate or poor quality sleep
• Dehydration
• Food and/or drink
• Hormonal changes

Activity Contributors

These are factors that relate to what you do throughout your day. Examples include:

• Positional changes, such looking up or down
• Movements, such as bending over, turning your head, lying down in bed or getting up quickly
• Visual, such as being in busy rooms with lots of people, looking at fans or windshield wipers, going to shopping malls, or being in a grocery store aisle
• Activities of daily life, such as working at a computer, taking care of kids or pets, washing dishes, gardening or vacuuming the floor

Social-Emotional Contributors

These are factors relating to your mood, level of social activity and level of social support from loved ones, friends, co-workers, bosses, and any other important people in your life. Examples include:

• Stress/anxiety
• Depression
• Feeling isolated or unsupported
• Having to socialize and talk to lots of people
• Having a doctor who tells you your symptoms are all in your head
• Not enjoying your job

Step 4: Identify Fatigue Triggers You Can Modify

Looking back at the list of contributors to your fatigue, identify the ones you can eliminate, control or plan around.

Controlling Biological Contributors

In many cases, triggers falling into this category are ones that you can modify with medical management or changes to your lifestyle. Triggering foods or drinks can be reduced or eliminated.

Dehydration can be mitigated by drinking more fluids throughout the day. Sleep disturbances can be helped by ensuring you get sunlight in the morning, turning off bright lights and screens an hour or two before bed, and having a set sleep/wake schedule. Hormonal imbalances may be helped by exercise or may need medical management. Which of your biological triggers would you be able to control with simple lifestyle changes and/or with a physician’s help?

Controlling Activity Contributors

Of course, you don’t want to eliminate positions, movements or activities from your life! That said, if you have several triggers from this category, it’s wise to create a strategy for dealing with them. If you know, for example, that several household chores trigger symptoms, you could spread them out throughout the week so you’re not putting as much strain on yourself at once. A good vestibular therapist can also work on some of these triggers with you to help reduce your sensitivity to them (see Step 5).

Controlling Social/Emotional Contributors

For factors in this category, spend some time finding out your tolerance or capacity for various triggers. Some triggers may be very draining, and others less so, but when they happen at the same time, they might cause a lot of fatigue. For example, having a stressful day at work and having to go to a big social gathering might be more draining than just going to a social gathering. What factors affect how much fatigue you feel in response to your triggers?

Below, you will find some lifestyle suggestions that may help you manage some of these factors.

Managing Stress, Anxiety and Depression

• Mindfulness meditation (many free meditations are available on YouTube, including this dizziness specific body scan)
• Self hypnosis (Reveri is a free self hypnosis app developed by Stanford professors and is available on the app store)
• Grounding/anchoring (see this example from Mayo Clinic)
• Deep breathing (see an exercise I often give dizzy patients here)
• Take a walk outside
• Spend time with a pet
• Do yoga or other exercise
• Talk to a friend
• Garden or just spend time outside
• Read a favorite book
• Listen to music
• Seek medical management if you are having difficulty coping

Socializing

• Be aware of what your other triggers are (visual, noise, etc.) and control those as much as possible
• Stand in a wide stance- it is less work for your vestibular system to stand in this position
• Find a quieter corner- loud noise/lots of activity are much more stimulating and can lead to faster onset of fatigue
• Face the wall, not the crowd, when talking to friends- a bustling room full of activity is harder on your eyes and brain than still objects
• Take recharge breaks- find a quiet place to breathe, sit or meditate once you feel symptoms to allow your body to recover
• Many people with vestibular orders find it easier to socialize in small groups and in quieter, less busy environments. For example, it might be easier to enjoy time with friends at a small restaurant versus at a large, busy one.

Step 5: Manage Movement & Visual Triggers

Fatigue and episodes of dizziness sometimes go hand-in-hand; other times, they may not seem related. However, for people with vestibular disorders, certain movements, positions and visual stimuli may be more likely to trigger fatigue. Even when you are not experiencing actual dizziness, vertigo or balance symptoms, your brain often has to work harder just to know where you are in space and keep you stable, as was discussed in Step 1. This is why it is so important to determine if you have movement or visual triggers, and to address them. For many people with vestibular disorders, vestibular rehabilitation therapy is very helpful in teaching your brain to adapt or get less sensitive to those triggers. This may help reduce the effort your brain has to put into stabilizing you, and make you less prone to having fatigue. This is true even for people with vestibular disorders that cause episodes of severe vertigo, such as Meniere’s Disease and vestibular migraine. Many people with such disorders find themselves more prone to fatigue even between episodes because their vestibular systems don’t fully recalibrate between episodes. Vestibular rehabilitation therapy can help address such symptoms.

Step 6: Plan!

Now you’ve figured out what your fatigue triggers are, how they relate to each other and how they affect you. You also have some ideas about which ones you can manage, either by yourself or with others’ help. The next step is to put everything you’ve learned into action by creating a weekly plan for managing your fatigue. Create a schedule for yourself in which you plan carefully around triggers. In general, you want to ensure you always have the recovery time you need between triggers. Some lifestyle modifications or stress reduction strategies, like talking a walk, exercising or talking to a friend, should also be scheduled in your plan. Once you’ve tried it out for a week or two, you can modify it based on what you found. Did you overdo it on one day and end up more fatigued? Did you find you had more capacity than you thought you did?

Another option is to create a “graded exposure” plan. The idea of graded exposure is to slowly increase your tolerance for certain activities systematically over time. In other words, you pick a goal activity and slowly increase the amount of time you spend doing it. Here’s how to do it:

1. Pick ONE goal activity- for example, walking outside daily for 30 minutes.
2. Pick a starting point by writing down how long you can do this activity with your present symptoms. If your symptoms come and go, average together how long you can do this activity on a good day vs. on a bad day.
3. Schedule your activity, even if it’s just for a few minutes a day, and stick to your schedule. Over time, your brain and body will become accustomed to the activity.
4. After a week or two of successfully completing the activity, add 2 minutes.
5. Continue doing your activity, slowly adding on time week over week until you reach your goal.

Step 7: Communicate With Others

There is no way around it- we are social creatures (yes, even you introverts out there!). How others respond to your vestibular disorder and accompanying symptoms can have a profound effect on how well you cope with them. How many of you have been told that your fatigue is “all in your head” or that you need to just push through? These unhelpful (albeit well-meaning) approaches can often raise feelings of guilt, shame or even grief over your capacity for activity. As you now know, those can lead to even more symptoms. Therefore, it is very important that you advocate for yourself in order to receive the social support you need.

One impactful method is to educate those around you about vestibular disorders. You can point them to the Vestibular Disorders Association website, ask them to attend a support meeting with you, or perhaps even share articles that explain how your symptoms affect your life and why. Sometimes, people just don’t have the facts, and sharing them might help them relate to you differently.

Another approach is to help others understand how they can be supportive. Oftentimes, those that care about you want to help- they just don’t know how. Take a moment to think about someone in your life who did respond in a helpful way to a symptom you’ve had. If you haven’t had anyone respond in a helpful way, you can think, again, of the kindest, most empathetic person you know. Make a list of the helpful responses you’ve had, or wish you’d had. Here are a few ideas to get you started:

• Checking in during activities or situations that are difficult for you (“We’re in a noisy restaurant and I know that’s hard for you- how are you doing right now?”)
• Providing grounding through physical touch or kind words
• Taking breaks with you during triggering activities
• Having a signal to let a friend or loved one know when you need a break
• Offering to attend a yoga or other exercise class with you
• Attending a support group with you
• Choosing venues that are more “vestibular friendly” for activities

As you can see, these are much easier to put into action when you know which contributors are most affecting your fatigue! Once you’ve made your list, have conversations with the key people in your life who can put them into action.

Step 8: Other Strategies

While the gold standard treatments for vestibular disorders and fatigue remain medical treatments, physical therapy and cognitive-behavioral therapy, new research is exploring alternative treatments. Most of this research is in the realm of chronic fatigue and pain management rather than vestibular disorders, but at least some researchers theorize that they work through changing patterns of activation in the nervous system. If this is true, these complementary approaches may be worth exploring.

• Supplements such as magnesium, vitamin B12, vitamin D and NADH have been explored for use in chronic fatigue syndrome. Ask your physician if these or any other supplements may help with your fatigue.
• Mindfulness meditation, mindfulness-based stress reduction and self hypnosis all have evidence supporting their use for managing fatigue, chronic pain and stress.
• Some research suggests that acupuncture may reduce fatigue in patients with cancer and chronic fatigue syndrome. It has also been shown to reduce pain in some patients with chronic pain.
• Massage and chiropractic care have evidence supporting their use for chronic pain.

Conclusion

The steps outlined in this article should help you develop your own fatigue management plan. It will take some work, but take confidence in knowing that you have many tools to help you. While fatigue is a common and distressing symptom that affects many people with vestibular disorders, you can learn to manage your fatigue and improve your quality of life.

Dr. Yonit Arthur, AuD