Brain fog is not an official medical diagnosis but a colloquial term for a range of significant, persistent cognitive impairments that cause such symptoms as sluggish thinking, difficulty processing information, forgetfulness, and an inability to focus, pay attention, or concentrate. These symptoms make it difficult for a person to perform routine tasks like holding a conversation, listening to instructions, or remembering the steps of a task. Unlike a progressive neurodegenerative condition like dementia, brain fog is usually a temporary disturbance with many possible underlying causes. There are numerous medical conditions that are associated with brain fog with the most recent example being post COVID-19 (or long COVID) brain fog. Over the years, I have been referred patients by their primary care doctors to help them restore optimal functioning even when the medical cause is clearly identified. In this article, I will focus on treatment strategies for this condition that have been found to be most helpful by patients, myself, and my psychiatric/medical colleagues.
Technically, brain fog could be considered part of the human condition. Even if it was mild and brief, most people could say they experienced some brain fog after a bad night of sleep, during a common cold, or some other infection. Usually, in these cases, the brain fog improves on its own as the body recovers from the source of the problem. Then, there are medical conditions that can be associated with brain fog and tend to have a preponderance in women: diabetes, hypoglycemia, hypo & hyperthyroidism, hormonal fluctuations (such as in pregnancy and menopause), inflammatory diseases (like irritable bowel syndrome or IBS), bacterial and viral illnesses, food allergies, autoimmune conditions (like Lupus and Lyme disease), multiple sclerosis, anemia, chronic fatigue syndrome, fibromyalgia/chronic pain, cancer, medication side effect, migraine headache, vitamin deficiency (such as B12, folate, and iron), traumatic brain injury, sleep disturbances, poorly managed stress, Major Depression and Attention Deficit Hyperactivity Disorder. Unfortunately, sometimes even when the underlying medical condition is treated, the brain fog can still persist in certain people.
What causes brain fog?
There hasn’t been a huge amount of research in this area but there is some agreement that brain fog is a multifaceted condition influenced by immune responses, brain metabolism, and oxygen delivery. The major theories include: 1) dysregulation in the blood-brain barrier which is a network of tissue and blood vessels that protect the brain from harmful substances, 2) gut-brain connection; for example, the SARS-CoV-2 virus that causes COVID persists in the gut after the infection has cleared up, and changes in the gut have been associated with changes in brain function, and 3) neuroinflammation in which inflammatory cytokines can disrupt brain activity and neurotransmitter function.
No single test confirms brain fog but a good neurological examination and cognitive testing can identify deficits in a person’s functioning.
Care and Treatment
Lifestyle strategies
Lifestyle strategies should be the foundation of any approach towards improving brain fog. In particular, I always highlight the 3 pillars of reducing inflammation in the body through diet, sleep, and exercise. As I discussed in a previous article, Should we all be on an anti-inflammatory diet, there should be a focus on a Mediterranean diet that reduces grains, dairy, and sugar. Anecdotally, many patients have commented that their post-COVID brain fog did improve in varying degrees by reducing all forms of sugar which would include hidden sources of sugar in juice, fruit, and alcohol. A gluten-free diet can also help certain people with brain fog. Exercise usually needs to start off small and gentle such as taking a 10-15 minute walk every day. On average, most adults need 7-8 hours of sleep per night and I believe it’s okay to take naps (less than 30 minutes) during the day to repay any sleep debt.
Other strategies include avoid “multitasking” which can take the form of simultaneously answering emails, phone calls, social media, text alerts, etc. If you’re having a particularly challenging day with brain fog, do what you consider easy tasks such as light stretches, sweeping a room or folding laundry—so that way you don’t get down on yourself for not being as productive as you would like. Taking frequent breaks every 20 minutes might be necessary and getting some sunshine or a gentle breeze outside can be refreshing. Many times, we can be so narrowly focused on things that are stressing us, we forget about “me time” which could be committing for up to an hour a day to have fun, smile and laugh at funny videos or memes.
Medication side effects
When I evaluate someone with brain fog without a clear cause, I go through their medication list to see if the date they were started on any particular medication correlates with the onset of brain fog. I believe any medication can cause any side effect even if it’s a rare side effect. Over the years, I have seen blood pressure medication, cholesterol medication, antihistamines, antibiotics, general anesthesia post-surgery, chemotherapy and psychiatric medications that have exacerbated brain fog. The medication, lamotrigine (Lamictal), is a great mood stabilizer but many people don’t realize that cognitive side effects start to become an issue as the dose gets increased towards 300 MG every day. Similarly, the medication, topiramate (Topamax), is used to prevent migraine headaches but also can lead to significant brain fog even at low doses for certain people.
Lymphatic Drainage Consultation
Assuming the lifestyle factors and possible medication side effects have been addressed, my primary recommendation for addressing brain fog may come as a surprise. Before I consider adding a medication to help with cognition, I recommend a lymphatic drainage consultation. Why you may ask? This is a low-risk intervention that is not painful or particularly expensive and actually can address the root cause of the problem—removing toxins from the body via your lymph nodes and a network of vessels that need to be moved out by a machine or manual stimulation. The brain fog does usually improve within a session or two but may require maintenance treatment every 3-4 months. I would not recommend this to anyone with blood clots, cellulitis, deep vein thrombosis, heart disease, kidney failure, or stroke.
Medication/supplement suggestions
If none of the above strategies makes a significant impact, I would then consider adding a cognitive enhancing medication to help memory such as donepezil or memantine. Perhaps a stimulant or bupropion for attentional deficits. Other studies have suggested NAD+ and Resveratrol (Cleveland Clinic) or the combination of Guanfacine and NAC (N-acetyl-cysteine) (Yale University) for COVID-related brain fog. Several of my colleagues have recommended neurofeedback or CPAP machine when appropriate. There has also been some interesting research by gastroenterologist (Dr. Reed Hogan) that suggests adding the combination of over-the-counter medications, Cetrizine (or Zyrtec which is a Histamine1 blocker) and Pepcid (Histamine2 blocker), can help brain fog related to IBS, fibromyalgia, and COVID.
As you can see, addressing brain fog is not a one size fits all approach. People can get very frustrated and demoralized when there doesn’t seem to be much improvement quickly. There is a certain trial and error process that may not yield 100% improvement but I have always seen some improvement. I believe in many cases there are multiple factors involved and so the treatment may require several of the approaches above simultaneously and over an extended period. Obviously, it’s important to have a good working relationship with your physician to get the best support in figuring out what works and what doesn’t work.