Brain Fog in EDS, POTS and Long COVID: Causes and Practical Ways to Cope

If you live with Ehlers Danlos syndrome (EDS), hypermobility spectrum disorder (HSD), POTS, MCAS, ME/CFS or Long Covid there is a good chance that you already know exactly what people mean when they talk about brain fog (1-4). It is that weird crushing feeling where your thoughts seem to be padded out, like swimming through treacle, where things you KNOW seem just out of reach. Words slip away mid-sentence, concentration disappears and even simple decisions become strangely overwhelming (2).

People frequently refer to it as if their brain has been enclosed in a cotton wool wrap. Not switched off just dulled, slowed and unreliable (2). More frustration is that it is invisible to everyone else.

Clinicians and researchers have tended to lump such experiences under the term “brain fog.”2,5 It is not a diagnosis in itself but a set of cognitive symptoms which includes poor attention, memory problems, slow processing speed and mental fatigue (2, 5, 6). Like trying to remember something you did even 5 minutes ago can sometimes seem impossible. Research to back up what patients have been saving for years! Brain fog is common throughout these conditions, and they have nothing to do with being lazy, not being intelligent enough or not trying hard enough (2,3,5).

Over time this constant brain fog eats away at our confidence, interferes with education, work and relationships and make people doubt their abilities or embarrassed to ask for accommodations that they genuinely need (3,7). That emotional cost is just as important as whatever the symptoms which are cognitive in nature (7,8).

Persistent brain fog can also be a useful signal. It may point toward underlying issues such as autonomic dysfunction, disrupted sleep, chronic inflammation, medication effects or altered blood flow to the brain (2,3,5,6). Many of these factors overlap heavily in EDS related conditions, which helps explain why brain fog shows up so often and why it can fluctuate from day to day (1,3,5).

That is what this article is about – making sense of all this. We will look at what brain fog actually is, why it is so common in EDS and related conditions and what we currently know, based on research, might be happening under the surface (1-3). From there we shall transition into practical and evidence based strategies that may help improve day to day thinking, without the pretending that there is one magic fix (7,9).

If you have ever felt that you were dismissed, confused or held responsible for symptomatology you cannot control then this is for you. You are not imagining it and you certainly are not alone (1-3)

What brain fog is, and what it is not

Brain fog is not an official medical diagnosis.(2) It is a patient led term people use to describe a very real group of cognitive difficulties such as forgetfulness, poor concentration, slow thinking and a deep sense of mental fatigue (2,5). The reason the term exists is not that there has not been a better everyday word for the experience, but because the experience itself is not vague or unimportant (5).

When researchers actually sit down and listen to patients the descriptions are very consistent. In studies of people with ME/CFS and ME/CFS-like conditions, study subjects tend to use words like cloudy, blurry, sluggish, and “walking through treacle” to try to explain what thinking feels like, losing their thoughts, having difficulty concentrating or going completely blank when trying to comprehend information (2,6). These are concrete experiences of cognitive strain which are not just abstract (2,6). Years ago I worked with a client who said that it was “opening your mouth and hoping the right sentence falls out” because by the time one finished with a thought, the beginning had already passed them by.

Similarly, surveys of teens and young adults with POTS show that brain fog is one of the most common and disruptive symptoms they report (1,3,10). Words like forgetful and cloudy come up again and again, alongside difficulty focusing, thinking, and communicating (1,3). Importantly, these self-reported experiences do not exist in isolation. they correlate with poorer performance on objective measures of working memory and information processing speed, showing that this is not just how people feel, but also how their brains are functioning in that moment (3,6).

Brain fog is not the same thing as the normal forgetfulness everyone experiences from time to time. We all lose our keys or forget a name now and then. With brain fog it is more like standing in your own kitchen and not remembering what a cupboard is for or staring at a familiar word until it looks wrong and you are not entirely sure you’ve spelled your own name correctly. Brain fog tends to be more persistent, more intrusive, and far more disruptive to daily life, often fluctuating alongside other symptoms such as fatigue, pain, orthostatic intolerance or allergy symptoms (2,4,5,11).

It is also important to be clear what is brain fog is not. Despite how frightening it can feel, especially as the words will not come out, or concentration drops dramatically, what is happening in the brain with brain fog issues in conditions like POTS, ME/CFS and EDS, is very different to that in neurodegenerative dementia (2,6). Cognitive testing usually reflects specific deficits in attention, working memory, and speed of processing, but not progressive and global cognitive impairments, which are the hallmark of dementias.(2,6) That distinction is important, both medically and in terms of the patient’s emotions.

Brain fog can be debilitating but it very definitely behaves in a very different way to degenerative conditions (2,6) we will begin to unfold the answer in more detail to why certain cognitive systems are so vulnerable in EDS/HSD conditions & what that tells us about where brain fog really is coming from (1-3,5)

How common is brain fog in these conditions?

One reason why brain fog results in so much frustration is how pervasive it is in EDS related and related/similar conditions (1,4,11). Once you began to look for it, it turns out to be in a lot of different groups of diagnosis.

In people with POTS, the problem of brain fog seems to be extremely common. In an internet wide survey of 138 people with physician diagnosed POTS, 96% reported brain fog as symptoms and most of them rated this as one of their most difficult symptoms (1). For many it was not an occasional annoyance, it was it every day (1,3). For one client I spoke with that “limiter” came up each and every time she tried to revise for exams. She would read the same paragraph over and over and over only to realise five minutes later that she couldn’t remember a sentence of it 

That personal experience causes you to agree with what we were seeing in the lab. Objective testing has shown again and gain that people with POTS do have quantifiable problems with attention and with their working memory and speed of processing that are particularly pronounced when their brain is challenged, whether that means a long cognitive task (like studying for an exam, or working through something tough) or being upright for long periods of time (3,6).

Among people with hypermobile EDS and HSD formal study results of the prevalences of the concept of brain fog are still emerging, but observational work and patient reported data describe high prevalence of cognitive complaints, usually alongside fatigue, pain, autonomic symptoms and disrupted sleep (4,11,12). Brain fog rarely happens in isolation, it comes as part of a larger pattern which makes it easier to shrug off if you are not looking closely, which happens a lot to people with these conditions. (4,11,12)

For people with ME /CFS, cognitive problems are almost a guarantee. Most patients report them early in their illness and systematic reviews consistently find impairments in attention, memory information processing, and often worsen after physical or cognitive exertion in line with post exertional symptom flares (2,6,13). A common story goes like this: you get through a family event or a work presentation, it is a good feeling that you got through it and proceed to spend the next two days unable to follow a simple TV plot.

Long Covid has thrown yet another group into this picture. Across several different groups, high rates of persistent cognitive dysfunction are reported months or even years after the initial infection with brain fog frequently stated among the most frequent complaints, and often in combination with dysautonomia, sleep disturbance as well as fatigue (4,8,13)

In mast cell disorders, including MCAS, the data are less tidy but still noticeable. Case series and surveys suggest that a high proportion of people with MCAS report cognitive difficulties and “brain fog” along with other mast cell symptoms such as flushing, gastrointestinal problems and headaches (11,14,15). High quality prevalence figures are still limited so that any precise percentage need be taken as tentative rather than exact. Taken together, this tells us an important something. Brain fog is not a niche or rare feature of these conditions, it is a core part of the lived experience to many people (1-4,8,11). The next step is the understanding of why it is recurring in various diagnoses, and what these common patterns can teach us about what is going on in the brain and nervous system (2,3,5).

Biological mechanisms that can drive brain fog

Brain fog is rarely ever an emanation of one. For most people it is the result of several systems being under strain at the same time, and which mechanism are predominant can change from by the day or even hour, depending on posture, pain, sleep, hormones, illness or cognitive demand.(2-4,8) That is one of the reasons brain fog can be so unpredictable and one of the things that makes so many people feel helpless as they deal with it.

Autonomic dysfunction and cerebral blood flow

In cases like POTS, autonomic dysfunction will be one of the most common biological causes of brain fog. 3,5,6 POTS is defined by excessive increase in heart rate on standing (but often there are symptoms of light headed, palpitations, fatigue and cognitive problems as well (5,16).

When a person suffering from POTS changes from prone to the upright or standing position this blood is prone to pool up in the lower body instead of effectively returning to the heart, decreasing their effective stroke volume and affecting their ability to effectively control blood flow to the brain.5,16 This is why something as mundane as standing in a hot shower or standing in a queue to buy something, is suddenly perceived as if your brain has gone dimmer when technically, you are still standing upright and functioning. Imaging studies using transcranial Doppler show that people with POTS experience greater decreases in blood flow velocity through the brain in response to orthostatic stress than normal people as a common surrogate for the decreased blood supply to the brain (6).

In a tilt table study of people with ME/CFS and POTS, as orthostatic stress increased, there were progressive declines in working memory and information processing and they were closely correlated with declines in cerebral blood flow velocity (3). This informs us that when the flow of blood was reduced, the same occurred with their cognitive performance (3). In another study, which was a sustained seated cognitive stress test, people with POTS developed significant decreases in cerebral blood flow velocity during a 30 minute task accompanied by deterioration of concentration and slowing of psychomotor speed and this was even without standing (6).

Taken together, what this tells us is that these findings help us understand why it is possible to experience a brain fog during the course of typical day to day activities. You do not have to faint or even feel obviously dizzy for the brain to be functioning with any less oxygen and nutrients. Slower thought and mental fatigue may appear from the background, without notice (3,6).

Chronic pain and central sensitisation

Chronic pain is very common in hEDS, HSD and EDS.(4,11,12) Pain is not only a messaging. It exercises the brain unkindly and places pressure on the brain under constant stress. Neuroimaging studies in a range of chronic pain problems reveal impaired connectivity in systems involved in attention and executive function, and individuals who are living with persistent pain tend to perform poorly on tasks that require divisible attention, working memory or rapid processing of information (11,17).

For the person with EDS or HSD it can mean that the brain may be as much focus can be on monitoring the position of the joint, predicting movement, and modulating your pain (reducing pain, putting protective mechanisms in motion to keep the joint in position), so that there is less resources available to read, plan, or carry on a conversation. (4,11,12). I have been told in the past by clients that they could have a conversation, or balance themselves as they walked across a crowded room, but not both comfortably. Part of their brain is busy keeping track of tracking – silently, every step of every joint, every move it might possibly go wrong. Pain also interferes with the ability to sleep, makes fatigue worse & adds to the mood symptoms. Each of those things can further impair cognitive efficiency creating a loop that can be difficult to break (11,17).

Sleep disturbance and circadian disruption

Sleep problems are very common in ME/CFS, long Covid and EDS related conditions: Insomnia, poor quality of sleep, broken nights and changes in time of sleep are all commonly reported (4,8,13,18). Both clinical and normal populations have been individually linked to attention and memory problems for each of these (8,18).

In long Covid clinic large parts of patients complain of new or exacerbated sleep disturbance, with both insomnia and hypersomnia, which have a strong correlation with a decrement in cognitive and functional capacity (8). Short or interrupted sleep causes reduced synaptic plasticity (ability of the brain to strengthen or weaken communication strength between neurons over time based on the levels of activity) and poor glymphatic clearance (the system that is responsible for removing metabolic waste from the brain) and in otherwise healthy people, poor sleep is associated with slower reaction times, working memory that is less effective and experiences with brain fog (8,18).

For those with autonomic dysfunction, night time symptoms of tachycardia, temperature instability, reflux or pain, may interrupt sleep on a repeated basis, often leading to significantly worse cognitive symptoms the next day (4,8,18).

Mast cells, microglia, and neuroinflammation

Mast cells are immune cells which are located all around the body this includes around blood vessels and contained within the meninges (the three protective, fibrous connective tissue membranes (dura mater, arachnoid mater and Pia mater) covering the brain and spinal cord) (11,14,19). Upon activation they release mediators such as histamine, cytokines and proteases that have the ability to influence the permeability of the blood brain barrier and signalling in nerve cells (11).

Experimental work suggests that mast cell activation can influence microglia, the resident immune cells of the brain and lead to the promotion of a state of neuroinflammation that can change the function of neurons, effect mood and cognitive function (11,19). Theoharides and colleagues has suggested that in conditions like MCAS and long covid, chronic mast cell activation and microglial priming of the brain may lead to symptoms like brain fog, fatigue and ‘chemobrain’ although large controlled human studies are still unfortunately limited (11,19).

Clinical cases and observational reports have repeatedly linked mast mast cell related conditions to high rates of cognitive and neuropsychiatric symptoms, such as brain fog, anxiety, low mood, and sleep disturbance (14,15,19). It is important to be clear, though, neuroinflammation is a plausible mechanism in some patients, but current evidence does not show that mast cell driven neuroinflammation is the sole or dominant cause of brain fog in everyone with MCAS, EDS or related conditions 14,19.

Post‑viral syndromes including ME/CFS and long COVID

ME/CFS and long Covid share a number of defining features, including persistent fatigue, worsening of symptoms of post exertion, autonomic dysfunction and brain fog (2,4,8,13). Neuroimaging reviews of ME/CFS have findings of subtle but consistent changes in brain areas related to attention and memory alterations and a few neuroimaging studies have markers consistent with neuroinflammation in subsets of patients (2,13).

In long covid, high rates of dysautonomia such as POTS and orthostatic intolerance have been documented which can trigger the same brain fog but via the same blood flow and autonomic mechanisms already described (4,8). On top of this,  sleep disturbance, chronic pain, mood symptoms, and possible mitochondrial dysfunction create a network of stressors, each chipping away at cognitive efficiency (4,8,13).

Metabolic and electrolyte factors

Even mild dehydration may impair attention, executive function has an affect on mood. Experimental studies conducted in healthy adults have shown losses as low as 1 or 2% of body weight to be sufficient to slow down reaction times and cause increased perceptions of mental effort.(11,20) In POTS a small trial has shown that drinking 500 ml water within a short period of time improved orthostatic tachycardia and some measures of cognitive performance during upright tilt presumably through an acute increase in blood volume and vascular tone21, 6.

Electrolytes such as sodium, potassium and magnesium are important to provide the generation and transmission of electrical signals essential in brain cells called neurons and both deficiency and excess can affect one’s thinking (11,20). Low sodium or potassium are recognised causes of confusion and cognitive and more subtle, chronic, imbalances may be beneath milder, but persistent cognitive complaints.20 Magnesium is involved in energy generation and synaptic function studies have correlated low magnesium status with lower memory function and increased risk of cognitive impairment.(11,20) High quality trials in EDS brain fog are limited.

Hormones and life stages

It is a known fact that hormonal fluctuations throughout the menstrual cycle, pregnancy, postpartum period and menopause influence aspects of the sleep cycle, temperature regulation, mood and cognition across the general population(18,20). More and more people who have EDS or HSD report worsening of orthostatic symptoms and cognitive problems at some points in their cycle, albeit the combination of these symptoms and evidence is not well studied in this particular population so these patterns are best considered as common clinical observations rather than rigidly quantified effects.(4,11,12)

Thyroid Hormones are another very important factor. Both underactive thyroids and overactive thyroids can result in slowing of the cognitive function, poor concentration and memory problems due to the effect on energy metabolism and brain function (11,20).

Medications and other reversible medical causes

A wide range of medications that are commonly used in EDS conditions may may impair the brain. These are sedating antihistamine, opioids, benzodiazepines, some antidepressants, anticholinergic drugs, and muscle relaxants (11,20). There is also many medical contributors to brain fog which are easy to miss such as anaemia, B12 or folate deficiency, uncontrolled diabetes, vitamin D deficiency, untreated sleep apnoea and thyroid dysfunction (8,11,18,20).

When someone lives with a complex chronic condition it is very tempting for all symptoms of cognitive nature to routinely be labelled EDS or POTS. That shortcut can be costly. Identifying and treating reversible contributors can serve as making a meaningful difference to day to day functioning (8,11,18).

How EDS and hypermobility increase vulnerability

EDS and hypermobility do not just affect how far joints move. They alter the behaviour of connective tissue, both in the body overall and in the ligaments and blood vessels, and frequently they overlap with autonomic dysfunction (4,11,12,16). Because vascular connective tissue is laxer when you are upright, conditions in which blood is not efficiently pushed back toward the heart, pooling, and you are likely to experience orthostatic intolerance may be more common (5,16). Over time, that makes it difficult to maintain consistent circulation to the brain and results in susceptibility to orthostatic intolerance and POTS (5,16).

This can make sense on a clinical level. Autonomic symptoms are prevalent in patients with EDS and HSD which palpitations, dizziness, exercise intolerance, temperature regulation problems, and brain fog are common again (4,11,12,16). In some cases these symptoms are dramatic and in other cases they really sit in the background and are secretly stealing away energy and clarity of mind.

Joint instability is one more cognitive requirement. If joints do not provide the brain with reliable feedback the brain has to be switched on to maintain posture, balance and movement under control and where pain is part of the picture the load gets further increased(4,11,12). It is not hard to understand how mental fatigue creeps in.

There are also smaller subgroups within hypermobiles who have additional conditions such as craniocervical instability or Chiari I malformation, structural changes around the base of the skull which will potentially lead to compressed nerve structures or changes in flow of cerebrospinal fluid (11,16). Case reports show a link to these issues with headaches, dizzy spells and cognitive symptoms but population data is limited and decisions around surgery are complex and require great expertise so this is an area where nuance and expert input rather than blanket assumptions is needed.(11,16)

The role of mental health and stress

Living with chronic symptoms that constantly fluctuation is hard. Being dismissed and having to wait years for answers and lose your independence or identity all makes a mark (7,9,22). It is therefore, not surprising that anxiety and depression are more common in conditions like POTS and EDS , than in healthy controls and these mood symptoms are associated with more severe self reported symptoms of brain fog and poorer performance in some cognitive tasks (7,9,22). Everybody I’ve been lucky enough to work with who have this going on can recall the actual appointment where they were told “it’s just stress” or “you’re over-thinking it” and that memory is in the back of their mind every time they want to ask for help again.

Trauma is also a factor that contributes to many people. PTSD is a condition for which nowadays increasing recognition is given in those living with chronic pain and long term medical conditions and is associated with attention being drawn towards threat, diminishing of working memory capacity and a perception of constant cognitive overload (17,22). When your nervous system is stuck in protection mode clear thinking is much more difficult (17,22) An observer may see it as “just” filling in a form or answering a reply to an email, but if your body is perceiving it as a possible threat, the attention is focused on every possible danger out there and you do not really have much bandwidth to remember what you were trying to say.

This is not to say that brain fog is “just psychological.” Psychological and biological processes interact and essentially can ping off each other constantly. Stress has impact on sleep, pain sensitivity, autonomic functioning and immune signalling; these physical symptoms, in turn, both perpetuate anxiety and low moods.(11, 8, 17) Stress itself can cause the autonomic nervous system and mast cells can become activated, which can aggravate dysautonomia and inflammatory pathways, so making a special effort to deal with trauma, anxiety and depression can be about lowering one of the many pressures on an already overloaded system, not minimising physical illness.(11,14,17,19).

Assessing brain fog: what to discuss with your clinician

A great assessment is going to start with labels not just the orations. When did the brain fog begin? How does it actually feel? Is it a trouble of words, slower thinking, memory lapses or mental exhaustion? What makes it worse & what makes it go away? Posture, heat, exertion, pain, poor sleep, stress or flare of allergy could all be relevant (1-3,7).

Some patterns are potentially very informative. Brain fog compounded by poor standing, and occurring after hot showers and in warm environments may be a sign of the possibility of Orthostatic Intolerance or POTS (5,16). Flares related to swallowed food, or extreme exposure to olfactory and/or allergen exposure may indicate mast cell factor (14,15,19). So fog which is closely suggestive of the symptoms of insomnia or sleep apnoea then they may want to consider sleep assessment a priority (8,18).

Blood tests are commonly a part of a sound work up, but not because they explain everything, instead because they are capable of pinpointing some common players in the list that often are treatable. This usually includes Cheques for anaemia, Iron status, B12, folate, thyroid function and glucose, vitamin D and other markers may be considered as well.(8,11,18,20) Fixing anything simple at the back of the mind will sometimes clear the mind of unimaginable cognitive fog.

As important is the medication review. Sedating antihistamines, opioids, anticholinergic drugs, benzodiazepines, muscle relaxants and some anti-depressants can all affect attention and memory (11,20). Sometimes it is not around stopping a medication completely, but finding alternative ways of timing or dosing medications or selecting alternatives with less cognitive side effects(11,20).

Neuropsychological testing is not always necessary but can be useful in cases where there has been any doubt about what is going on, if accommodation will be necessary for work or education, or if there is concern about an aggravating neurological condition rather than fluctuating brain fog. (2,7,9,22)There are also cases that require urgent attention such as suddenly worsening cognition, new neurological deficits, seizures, sudden personality change or severe headaches with neurological signs should never be brushed off and require prompt assessment to rule out serious causes such as stroke, infection or autoimmune neurological conditions.(7,18,20)

The bottom line is simple. Brain fog will also deserve to be taken seriously and that it should be never been ignored. A careful and curious approach that seeks patterns as well as reversible contribution can make a real difference to day to day life (7-9).

Day‑to‑day strategies: foundations for clearer thinking

There is no magic solution that gets rid of the brain fog once and for all. But there are some foundations for thinking to become more steady and predictable in long run. None of these has anything to do with pushing harder, it has to do with working with the way your system actually acts (7-9,13).

Energy management and pacing

In ME/CFS and long covid, pacing the approach to symptom management is a mainstay in symptom management, and the same idea is beneficial in managing symptoms of brain fog in EDS, Pot’s and MCAS (2,4,8,13). A good way to think regarding quite certainly is the cognitive, the bodily, the emotional all get bingo at the same time from the same pool of finite power. Initially one can expenditures too much in one area, the price of which is often mirrored later in heavier brain fog, sometime later the same day, or the next(2,7,9).

Some people find it helpful to sort out tasks loosely. High load tasks could include complicated work, difficult discussions, appointments or solving a problem. Medium load tasks take attention and not too much deep focus. Low load-tasks are simple, familiar or restorative. The goal is definitely not to label perfectly everything we do, but it also is not to load too many high load tasks together (7,9).

Timing matters too. Most people have a window when their thinking is clearest very often late morning, however this varies so scheduling demanding tasks into this window can make them more manageable and reduce the spiral of frustration that comes from trying to think clearly when your brain simply is not there (7). Short strings of intense work, after conscious, cognitive breaks, can prevent the insidious overexerting sneaking up on you here and there. It is easy to overlook the warning signs until suddenly the fog in the brain crashes in later (7,9).

Sleep hygiene and insomnia strategies

Sleep has an outsized role in cognitive function and for many people, improved sleep is literally one of the best return strategies implemented to reduce brain fog (8,13,18). Consistency is better than perfection: If you can go to sleep and wake up at about the same time, cater to “more consistent” evenings less in chaos and limit bright light and stimulating screens before bed, all those may help the brain to unsettle (18).

Pain tends to usually be a saboteur of sleep especially with hypermobility. Addressing pain earlier in the evening, use of supportive pillows, as well as braces if recommended as well as changing bedding in order to offer ease to the joints can make a real difference (4,11,12). For persistent insomnia, a form of psychological treatment known as cognitive behavioural therapy for insomnia (CBT I) is well-proven and flexible for people with chronic illness, and it involves re-gaining trust of your brain and sleep, as opposed to trying to force your body to sleep (18).

If there are signs of sleep apnoea including loud snoring, pauses in breathing, gasping in sleep or even feelings of being completely unrefreshed despite getting enough time in bed then a sleep study is important. Treating apnoea can improve the thinking of some people dramatically during the day (18,20).

Movement and physical conditioning adapted for EDS and POTS

Movement supports brain fog in several ways. It helps blood flow, supports autonomic regulation, and over time can reduce pain, but with EDS and POTS it has to be approached carefully (4,5,16). Many POTS protocols start with recumbent or semi recumbent exercise. Things like recumbent cycling, rowing, or supine leg and core work, build muscle pump function without triggering orthostatic symptoms too early (5,16,23).

Movement need not be in the form of formal exercise. Short and gentle bouts spread throughout the day, of calf raises, light marching or short stretches, will ensure pooling down occurs during long stretches of sitting or perhaps, making cognitive clarity a little more keen for some people (5,7). As the joint instability is part of the picture in hEDS and HSD, working with a physiotherapist with an understanding of hypermobility, with the goal as stability and control rather than maximum range can be invaluable.(4,11,12,23)

Progress must be slow and by degrees. Delayed if not, flare up of symptoms is common. Spread writing a simple activity and symptom diary, it can also help you to look for patterns that increases are helping or quietly costing you at a later stage, especially if you experience a post exertional worsening of symptoms. (2,13,23)

Environment and sensory load

The dissection on the brain fog is not only the inner nature. Environment is more important than people seem to realise. Busy, noisy, bright or hot environments increase cognitive load and autonomic activation and for someone in a vulnerable position that can cause thinking to be tipped over the edge in a short time (5,7,16).

Many people make use of practical devices in respect of this and they happen in the following manner: Noise cancelling headphones Sunglasses or hats Cooling devices. These are not indulgences, they are ways of not putting undue strain on shops, classrooms, offices or public transport (5,7). A special mention should be made of heat. Warm environments lead to an expansion of the blood vessels and perhaps interfere with the symptoms of orthostatic intolerance. Staying cool by the usage of fans, cool drinks and avoiding long hot showers can assist to ease both the physical symptoms along with the brain fog (5,16).

Visual clutter is also another source of added load. Simplifying a work space, closing up unnecessary tabs and eliminating visual noise, can make it easier for you to orient yourself easier and follow tasks through to completion, even cleaning up a bit in the area you are spending time in. (7,9)

Cognitive strategies

When the brain fog is bad it’s exhausting trying to have it all in your head. Simple systems are the best: To do lists, phone reminders, calendars, white boards, sticky notes (7,9,22). One or two cautiously utilised beat five systems occasionally utilised.

The breaking down of the tasks helps too. Large and vague tasks take a lot of executive function. Smaller (concrete) steps are easier to get started, and easier to accomplish and progress is more tangible, which is important when motivating is tenuous (7,9). Single tasking is typically more efficient than multitasking when resources of attention are limited20,22 and grouping similar tasks should make the mental cost of changing processes is lower7.

When word finding starts to get difficult slowness helps. Describing the idea or gesture, incorporating gesture or talking around the word can help communication to continue until it can catch up. Most people have more patience than we’re afraid to give them, especially if they know what’s going on. (2,26)

Self‑compassion and coping with guilt

Brain fog is not just a problem of thinking, but it is an attack on the identity. Many who struggle with it were high functioning and driven or perfectionists before. When thinking slows down, frustration, shame and self criticism rush in to take the place of the thinking.(7,9,22)

Self compassion is not giving up. It is learning that brain fog is real, quite common with chronic illness and not something that is your fault (7,9,22). No stress of self-attack decreases stress, and, just that brings free up some bandwidth of cognitive resources (17, 22). It can also help to be open with trustworthy people. Friends, family, colleagues, teachers or employers are not in a position to accommodate what they do not understand, and effective communication results in fewer misunderstandings and more likely support.(7,9)

Psychological methods, such as acceptance and commitment therapy or compassion focused therapy, can be of of particular use. They do not aim at getting rid of symptoms, they focus on helping people to build meaningful lives with uncertainty and cognitive variability (9,17,22). None of these strategies is on fixing you. They have to do with providing your brain with the conditions that it needs to do its best on any given day.\

Targeting specific contributors

Once the foundations are up, it may be helpful to look more at the more basic contributors to poor brain health and treat them directly. Not all of this will be applicable to all people, or anything for that matter, and it’s not about doing all of this. This is about having choices and choosing from those that suit your body and your situation (5,7,9).

Managing POTS‑related brain fog

For many people with POTS, brain fog has a very highly correlated with degree of control of orthostatic symptoms (1,3,5,6). One of these is just simple but can be sometimes effective – hydration, and especially using what is termed a water bolus. A small controlled study demonstrated a relatively short time was required to drink about 500 ml of water to reduce the phenomenon of orthostatic tachycardia and ameliorate some of the cognitive tests during tilt testing most likely mediated by stimulation of receptors in gut and portal circulation to increase vascular tone (6,21)

In the day to day life some people find that taking water before prolonged standing such as when showering or going shopping can take the edge off symptoms but obviously this is not universal and needs to be adapted to individual tolerance especially if there are heart or kidney conditions in the background.(5,16 ). Salt and electrolytes could be a factor as well. Dietary sodium supplementation, guided by a physician, may correct fluid volume depletion and enhance orthostatic tolerance in a significant number of patients with POTS, and electrolyte replacement drinks/solutions or oral rehydration salts may help maintain fluids and sodium concentration particularly during hot weather and/or during illness (5,16,23). Very high salt intake does not suit everybody, and this intake should also be overseen.

One of the other practical levers is compression garments targeting the abdomen and thighs, rather than the calves alone, are better at decreasing orthostatic manifestations(5,16). Physical counter manoeuvres can help too, leg crossing, tensing the legs and buttock muscles, calf raises, or marching on the spot can temporarily increase blood flow back to the heart and sometimes save a situation of short term loss of clarity of the mind.5,16

Exercise training can assist some individuals improve the symptoms of POTS especially if the exercise training starts as Recumbent Aerobic training and light resistance training (16,23). Brain fog outcomes have been studied much less and for the subset who have overlap with ME/CFS or post exertional symptoms the need for exercise for those with ME/CFS or PME is understood to be individualised and needs to be monitored carefully as pushing through often backfires (2,13,23). Drugs such as fludrocortisone, beta blockers, midodrine, ivabradine or others are used to influence the heart rate, blood volume or the tone of blood vessels. Some people feel the improvements in brain fog are improved when symptoms decrease of the orthostatic symptoms occur, however these medications do discussed side effects and interactions are obvious so the choice is up to the clinician that understands dysautonomia vs trial and error may be the best method (5,16,23).

Addressing MCAS‑related contributors

When mast cell activation comes into the picture, decreasing mediators release from the mast cells, sometimes leads to improve cognitive symptoms(11,14,15,19). Non sedating H1 antihistamines, for example cetirizine, loratadine or H2 blockers (for example famotidine) are often used in MCAS. Observational reports suggest that there are people who improve their physical and brain fog both using combined H1 and H2 blockade (14), although the existing high quality trials which focused on cognition specifically are very limited and more research is needed (15).

First generation antihistamines that are sedating is a different storey. Drugs such as diphenhydramine have negative effects on attention and memory and usually are not used during the day when you are already suffering from brain fog issues (11,20). Mast cells stabilisers are also used sometimes. Cromolyn Sodium is prescribed in some cases and, although the evidence comes chiefly from small studies, some people find thinking is much clearer when the mast cells are better under control (14,15,19)

Supplements like quercetin and luteolin can be heard a lot about them in the internet. They have mast cell stabilising and anti inflammatory properties in preclinical studies and small uncontrolled human studies suggest possible benefit in the neuroinflammatory symptoms but evidence is limited and they have known interactions with medications or are inappropriate to some people.(11,19) These are conversations to have with a good clinician not decisions to be made based on anecdotes only.

Diet can matter too. Some people find that decreasing high histamine or histamine liberating foods helps in decreasing the flares associated with eating histamine liberating foods including brain fog (14,15) although responses vary significant. Food lists can be a starting place but long term restriction without proper guidance can be risky regarding nutritional issues also. A dietitian who has familiarity in MCAS can help in a safer etc.

Managing sleep problems

Sleep warrants by itself an attention due to the extent to which sleep does influence cognition (8,13,18). In long covid clinics insomnia, hypersomnia and an mixed sleep patterns are prevalent and similar problems emerge with EDS, HSD and ME/CFS populations.(4,8,13,18) Non drug approaches like CBT I, stimulus control, sleep restriction therapy, relaxation techniques and circadian rhythm support have good evidence to improve quality and daytime functioning of sleeping life.18

When there are suspicions of certain conditions, such as restless legs syndrome, period limb movements and parasomnias, sleep studies can help to get a better understanding of what’s going on, and help to focus treatment. Improving sleep architecture may improve symptoms of brain fog by nothing more than changing the restfulness of sleep (18,20). Sleep medications need different evaluation on a regular basis. Sedative hypnotics and some anti-depressants or anti-psychotic medications can cause problems for cognitive, and these work effectively for a short time, but given their many other negative effects, the balance of helping you sleep and deadening your brain demands constant attention.(18,20).

Supporting mental health

Mental health care is far from when it comes to brain fog is an extra (7,9,22). Psychological therapies tailored to meet the needs of chronic illness such cognitive behaviour therapy (CBT), acceptance and commitment therapy (ACT), trauma focused therapies and mindfulness based approaches are all effective in reducing distress and cognitive burden; reduced worry, rumination and hypervigilance are often followed by increased attention and memory as a downstream effect.(9,17,22)

In POTS it has been shown that anxiety and depression are associated with poorer performances in domains of attention and short term memory (9,22). Addressing mood does not bring a problem up that it didn’t exist, it is taking another pressure off an already straitened system. When medications, such as, respectfully, SSRIs or SNRIs, are considered, this is because of possible benefit for mood, and sometimes autonomic symptoms, in some individuals, consideration needs to be given to which side-effects to consider (sedation, agitation, or sleep disruption), and these trade-offs look different for each person(9,20,22).

Nutrition, electrolytes, and micronutrients

Highly restrictive diets can contribute quiescently to the sometimes more dreaded deterioration in fatigue and in cognition due to calorie or micronutrient deficits (11,20); and, by the rigours that exert self imposition of a diet. In the process of assessment and treatment of insufficiency, clinicians frequently assess iron status, B12, folate, and vitamin D, because deficiencies in any of these may play some role in “off” cognition, even after levels are just marginally low.(11,20)

Omega 3 fatty acids have been associated with some but not empirical studies showing modest benefits in mood and focus but no specific research has been done to relate to EDS or POTS related brain fog. (11,20) Magnesium may benefit those individuals that are deficient or borderline but routine high dose supplementation in the absence of evidence of low status is not well supported (11,20).

Experimental and emerging ideas, with caution

There are also approaches being discussed that occupies firmly in the space of experimental. These are things good to know but not good to be blind to.

Some flavonoids especially luteolin have been hypothesised the brain fog in long covid, MCAS and chemotherapy related cognitive impairs. The interest is due to the animal studies and small series of humans that suggested anti inflammatory and mast cell stabilising effects respectively. (11,19) At the moment, evidence is weak, the dosing is confusing – and there is a low level of long term safety data. These have to be regarded as experimental adjuncts and not established treatments (11,19). Ketogenic and very low carbohydrate diets have also been worked upon. A recent review declared that nutritional ketosis might be beneficial in neurological symptoms from long covid as a way of providing an alternative brain fuel and reducing inflammation, but signals of benefit are early and based on small studies 24 These diets are restrictive and may have associated risks, especially in people with gastrointestinal problems or metabolic conditions and/or a history of eating disorders so they should only be undergone with medical and dietetic support (24).

Oxygen based therapies have been tried by some doctors in POTS & long covid based on the evidence of a significant decrease in blood flow to the brain with orthostatic stress.(6,8) Increasing Inspired Oxygen can increase oxygen content of the arterial blood but there are few controlled trials that specifically examine the outcome on brain fog, there are also the long term costs and potential risks of this addition (6,8). At present, this is still an experimentation approach which should only be reckoned to in specialist supervision. New ideas are worth investigating, however, doing less harm is always the objective (11,19,24.)

Working, studying, and parenting with brain fog

Brain fog is not very contained. It overflows into that part of life which depends most upon being able to think clearly and to keep regulated. Reading takes longer. Writing is hard harder than it should be Meetings fuzzyTogether. Conversations taken off at half an hour full stop. Time slips. Emotional bandwidth and this is reduced. When your job is working, studying or looking after other individuals, that cognitive drag can be quite fatiguing and at times deeply demoralising (7,9,22).

One important thing to know – support is not favour. In many countries, there are legal frameworks in place to grant reasonable adjustments in cases of people living with chronic health conditions and in some instances, documentation provided from a clinician and, sometimes neuropsychologist, can be used to assist in requests for accommodations without you having to over explain and justify yourself time and again (7,9,22). In practise though, what helps is often very simple: Recorded lectures or meetings so information can be replayed The use of written instructions instead of just relying on verbal instructions Lists for tasks that persist for outside your head Break down from pressure to multi-task Quiet in the work space The option to work remotely on days that symptoms are worse. (4)Though, here are some specific examples (7,9,22) None of these lower standards they lower the unnecessary frictions.

For students, that may be additional time in exams, rest breaks or different forms of assessment which are the difference between showcasing their understanding and being hindered by processing speed (7,13). These changes are not there for nothing.

Being a parent with the brain fog has problems of its own. Children require consistency, attention and emotional availability and that can be painfully difficult when you’re going slow or incoherent in your thinking. Many of the parents find one of the greatest benefits of simplification is simpler shared calendars, cooking on better days ahead of time, fewer keys to move around a week, etc. (7,9). Being honest, in an age appropriate way, helps, often, as well. Saying something like “my brain feels tired today” helps give children some framework that does not involve blame and fear and helps them to understand why a parent might be quieter, slower or need more rest that does not leave them feeling pushed away.(7,22)

None of this makes you a worse worker/student/parent. It makes you somebody adapting smartly with a nervous system that changes in fluctuations (7,9,22).

Putting it together: building a personalised plan

Brain fog is rarely ones size fits all as it very rarely comes from one place (2-4,7). The most effective way to do this would often be to step back and ask what are contributors doing the most damage right now, not generally, but right now.

For one individual, brain fog can be precipitated by standing, heat, and dehydration. In that case, attention to POTS management, hydration strategies, compression and cooling should bring the biggest gains (5,6,16,21,23). For another person, the fog may be caused primarily by insomnia, trauma or continued stress and sleep support and psychological support are the best places to begin (8,9,17,18,22).

These priorities are subject to change as time stakes are subject to change. What is important is being responsive and not rigid (7,9). Many people appreciated the out-of-the-box thinking of working with an interdisciplinary team amount because it was fancy but because it’s practical: for example, a clinician familiar with EDS or POTS or MCAS, a physiotherapist that understands hypermobility, a psychologist that works with chronic illness and where it is needed, a dietitian or occupational therapist (4,5,11,12,15,16,23). By these pieces communicating with each other the plan has a coherence rather than being overwhelming.

Tracking symptoms can be used to help more than people think. A simplistic journal or app of the severity of the brain fog, triggers, posture, sleep, medications and interventions may kick up patterns that are difficult to see on a day to day basis (7,9). Over time, this makes it easier to let go of what isn’t helping, avoid what makes things worse and then keep the things that really help increase clarity.(7,9)

The development of perfect cognition is not the goal. It is predictability: mental enough: ability to live often enough, one that matters to you (7,9,22). Brain fog may be a part of your storey but it does not get to be the whole storey.tive.

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