For MS Fatigue, Talk Therapy May Be as Effective as Medication

Key Takeaways

• Cognitive behavioral therapy and the mild stimulant modafinil both reduce fatigue in people with multiple sclerosis by about the same amount, finds a new study.
• Combining talk therapy and medication isn't better than using either intervention on its own.
• More than 60 percent of people with MS reported meaningful reductions in fatigue with cognitive behavioral therapy or modafinil.

People with multiple sclerosis (MS) can relieve fatigue just as well with talk therapy as they can with medication, a new study suggests.

Up to 90 percent of people with multiple sclerosis experience fatigue at some point, and nearly half of them describe fatigue as their most debilitating symptom, according to the study authors.

The scientists focused on three interventions: cognitive behavioral therapy, the drug modafinil, and a combination of both.

Cognitive behavioral therapy (CBT) is a type of talk therapy designed to help people recognize negative thoughts and respond to them differently. Modafinil (Provigil) is a mild stimulant that's often used by people with narcolepsy, sleep apnea, or sleep disorders caused by shift work.

Researchers asked the 336 study participants to rate their fatigue levels before they started treatment, and again 12 weeks later. By the end of the 12-week study period, participants experienced similar - and clinically meaningful - reductions in fatigue with both CBT delivered over the phone, modafinil taken once or twice a day, and a combination, according to findings published in The Lancet Neurology .

"Fatigue is one of the most common and debilitating symptoms of multiple sclerosis, yet there is still uncertainty about how available treatments should be used or how medication-based treatments compare to behavioral treatments in the real world," lead study author Tiffany Braley, MD , an associate professor of neurology at the Michigan Neuroscience Institute and the University of Michigan in Ann Arbor, said in a statement.

"This research offers new evidence to show that both CBT and modafinil are comparably effective for MS fatigue, which could shape treatment approaches to one of the most challenging symptoms experienced by people with multiple sclerosis," Dr. Braley said.

There didn't appear to be side effects associated with CBT in the new study. The most common side effects with modafinil were insomnia and anxiety.

Fatigue Is a Common MS Symptom

In the study, 65 percent of patients on CBT, 69 percent on modafinil, and 70 percent on combination therapy reported "clinically meaningful" reductions in fatigue, indicating that the interventions had a positive impact on their daily lives. But the results were not statistically significant, meaning the change in symptoms was too small to rule out the possibility that this finding was due to chance.

Even so, the results suggest that both CBT and medication may have a role in helping to relieve fatigue in multiple sclerosis patients, says Bardia Nourbakhsh, MD , an associate professor of neurology at Johns Hopkins University in Baltimore, Maryland, who wasn't involved in the new study.

How CBT May Help MS Fatigue

"CBT helps patients with multiple sclerosis to identify connections between their thoughts, emotions, and behaviors, especially those patterns that may be exacerbating their fatigue," Dr. Nourbakhsh says.

"This approach empowers individuals to develop new strategies to manage their energy, adjust unhelpful thoughts, and create healthier habits for handling fatigue," Nourbakhsh adds.

One open question, however, is whether study participants benefited simply from having a therapist to talk to or specifically from the therapy approaches used with CBT, Nourbakhsh says.

Modafinil May Work Best When Daytime Sleepiness Is Also an Issue

Modafinil doses varied widely in the study, suggesting that different people may respond differently to this medication. It's possible that this drug may work best for people who have both fatigue and excessive daytime sleepiness, Nourbakhsh says.

"Overall, in the absence of a study that shows medication is clearly better than a placebo in improving multiple sclerosis fatigue, I would recommend nonmedication approaches, such as CBT," Nourbakhsh says.

"However, in patients who have concomitant daytime sleepiness, I recommend being tested for sleep apnea or other sleep disorders," Nourbakhsh adds. "If there is no sleep disorder, or if fatigue and daytime sleepiness remain after treating the sleep disorder, modafinil might be a good option in this case."

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Sources

1. Braley T et al. Comparative Effectiveness of Cognitive Behavioural Therapy, Modafinil, and Their Combination for Treating Fatigue in Multiple Sclerosis (COMBO-MS): a Randomised, Statistician-Blinded, Parallel-Arm Trial. The Lancet Neurology . October 16, 2024.
2. For multiple sclerosis, medication and cognitive behavioral therapy can reduce fatigue. Eurekalert . October 16, 2024.

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Lisa Rapaport

Author

Lisa Rapaport is a journalist with more than 20 years of experience on the health beat as a writer and editor. She holds a master's degree from the UC Berkeley Graduate School of Journalism and spent a year as a Knight-Wallace journalism fellow at the University of Michigan. Her work has appeared in dozens of local and national media outlets, including Reuters, Bloomberg, WNYC, The Washington Post, Los Angeles Times , Scientific American , San Jose Mercury News , Oakland Tribune , Huffington Post, Yahoo! News, The Sacramento Bee , and The Buffalo News . See full bio See Our Editorial Policy Meet Our Health Expert Network