There is no single cure for long COVID, but a combination of symptom management strategies can significantly improve how you feel and function. Over 90% of long COVID patients in a large French study reported gradually decreasing symptoms over two years, with about 5% improving rapidly. The path forward involves identifying your specific symptoms, managing your energy carefully, and working with your body’s recovery process rather than pushing through it.
Long COVID is defined as symptoms lasting at least three months after a SARS-CoV-2 infection. It can affect multiple organ systems, and symptoms often follow a relapsing and remitting pattern, meaning you may feel better for a stretch and then worse again. That unpredictability is normal for this condition, not a sign you’re doing something wrong.
Pacing: The Most Important Skill to Learn
The single most effective strategy for managing long COVID is pacing, which means staying within your body’s reduced energy limits instead of pushing past them. When you overdo it, you trigger post-exertional malaise (PEM), a delayed crash that can set you back for days or weeks. PEM is the hallmark symptom that makes long COVID different from ordinary fatigue. It doesn’t respond to willpower, and it doesn’t get better if you “work through it.”
A heart rate monitor is the most reliable pacing tool. The goal is to identify your anaerobic threshold, the heart rate at which your body shifts from sustainable energy production to the kind that causes crashes. The Workwell Foundation recommends a simple starting estimate: measure your resting heart rate first thing in the morning for seven days, calculate the average, and add 15 beats per minute. If your average resting heart rate is 65, your estimated threshold is 80 bpm.
Throughout the day, try to keep your heart rate below that number. If it climbs above the threshold, stop what you’re doing and rest until your heart rate drops back to within 10 beats of your resting rate. Set an alarm on your monitor so you don’t have to constantly check. A chest strap like the Polar H10 tends to be more accurate than a wrist-based tracker. Keep a daily log of your activities and symptoms so you can spot patterns. Cognitive effort counts too: a stressful phone call or focused work session can spike your heart rate just as much as walking up stairs.
Why Exercise Can Make Things Worse
Graded exercise therapy, where you gradually increase physical activity over time, has been a standard recommendation for many chronic conditions. For long COVID with PEM, it can be harmful. Studies evaluating graded exercise found that over 50% of participants experienced adverse events, including serious deterioration in fatigue and physical functioning.
This doesn’t mean you should never move your body. It means that any physical activity needs to stay below your energy threshold. Gentle stretching, slow walks, or reclined exercises may be fine for some people. The key distinction is that activity should be guided by your symptoms and heart rate, not by a schedule that increases regardless of how you feel. If an activity feels “hard,” that’s your signal to stop.
Managing Dizziness and Racing Heart
Many people with long COVID develop dysautonomia, where the nervous system struggles to regulate heart rate and blood pressure, especially when standing. You might feel lightheaded when you get up, notice your heart pounding after a shower, or feel exhausted just from standing in line. These symptoms often fall under the umbrella of POTS (postural orthostatic tachycardia syndrome).
Practical measures that help: aim for about 2 liters (68 ounces) of fluid per day. If your doctor confirms you don’t have heart or kidney disease, increasing salt intake to 3 to 5 grams daily can help your body retain fluid and maintain blood pressure. Before any activity that requires standing, try drinking 12 to 16 ounces of cold water quickly. This can temporarily raise blood pressure enough to prevent symptoms.
When dizziness hits, physical counter-pressure maneuvers can push blood back toward your heart. Bend forward at the waist, rise up and down on your toes, slowly march in place, squat, or cross your legs tightly. These aren’t cures, but they can get you through moments that would otherwise force you to sit or lie down.
Clearing Brain Fog
Cognitive difficulties, often called brain fog, are among the most distressing long COVID symptoms. You might struggle to find words, lose your train of thought mid-sentence, or find it impossible to concentrate on tasks that used to be automatic.
The underlying problem appears to involve inflammation disrupting the brain’s prefrontal cortex, the region responsible for working memory, attention, and executive function. A combination treatment using N-acetylcysteine (NAC) at 600 mg daily and guanfacine (a prescription medication started at 1 mg and increased to 2 to 3 mg as needed) has shown improvement in cognitive functioning in preliminary findings from Yale researchers. NAC works as an antioxidant and helps reduce compounds that interfere with brain signaling, while guanfacine strengthens the connections between neurons in the prefrontal cortex. This combination requires a prescription and medical supervision for the guanfacine component, but NAC is available over the counter.
Beyond medication, cognitive pacing matters just as much as physical pacing. Break mental tasks into short blocks with rest periods. Reduce multitasking. Use external memory aids like lists, timers, and phone reminders without guilt.
Dietary Triggers and Histamine
Some long COVID patients develop mast cell activation symptoms: unexplained rashes, flushing, hives, gut problems, or reactions to foods they previously tolerated. If this sounds familiar, a low-histamine diet may help reduce the load on your immune system.
Foods to reduce or avoid include:
- Alcohol, especially fermented drinks like wine and beer
- Smoked and cured meats
- Seafood
- Pickled foods and vinegar
- Leftovers (histamine increases as cooked food sits)
- Canned fish or meat
- Strawberries and other berries
- Nightshades like tomatoes and potatoes
- Foods with preservatives
Taking DAO enzyme supplements with meals can also help your body break down histamine from food before it triggers symptoms. The UCSF Osher Center for Integrative Health recommends this diet specifically for long COVID patients with frequent rashes or elevated histamine markers. Not everyone with long COVID needs this approach, but if you notice that certain meals consistently make you feel worse, it’s worth a trial period of two to four weeks to see if symptoms improve.
Medications Under Investigation
No drug is currently approved specifically for long COVID, but several are being studied. Low-dose naltrexone (LDN) is one of the most discussed. Used at doses between 1 and 4.5 mg daily (far below the standard dose used for other conditions), it appears to have anti-inflammatory and pain-relieving properties. Clinical trials are underway but have not yet posted results. Some doctors prescribe it off-label, typically starting at 1 mg per day and gradually increasing over several weeks. It requires a prescription and is usually obtained through compounding pharmacies.
What Recovery Actually Looks Like
Recovery from long COVID is real but rarely linear. A two-year study tracking long COVID patients found that about 91% experienced slowly decreasing symptoms over time, while roughly 4% had symptoms that persisted with little change. The “slow decrease” pattern means you may not notice improvement week to week, but looking back over several months, the trend is usually positive.
Relapses are part of the pattern, not evidence of failure. Many people describe recovery as a sawtooth graph: overall upward, but with dips along the way. The dips often coincide with overdoing activity, new infections, stressful life events, or hormonal changes. Tracking your symptoms over time helps you see the larger trajectory even when individual days feel discouraging.
The combination of strict pacing, symptom-specific treatments, and time gives most people the best odds. Recovery timelines vary enormously. Some people improve substantially in six months, others take two years or longer. Protecting your energy envelope during this period isn’t giving up on activity. It’s the strategy most likely to expand what you can do over time.