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Magnesium & Malic Acid Supplementation Often Beneficial for CFS & FM Quality-of-Life Measures – Studies and Top Specialists Report

Clinical studies have consistently reported that Fibromyalgia and Chronic Fatigue Syndrome patients tend to be deficient in the essential mineral magnesium (Mg), and research indicates many may achieve quality-of-life benefits by adding supplemental Mg to their diets.(1,2,3)

Leading CFS and FM specialists routinely recommend magnesium supplementation to their patients specifically for support of improved muscle pain and fatigue. And most favor a combination of Mg plus malic acid, an extract of tart apples, as a dietary supplement for individuals with below-normal Mg in the blood and tissues.(4,5,6)

The Importance of Magnesium for Energy and Muscle Comfort

Magnesium plays a role in at least 300 biochemical functions in the body. One of the most important is that it activates almost all the enzymes involved in transforming fat and sugar into high-energy adenosine triphosphate (ATP), the body’s energy source, reports Georges Ramalanjaona, MD, an expert on the benefits of Mg supplementation for FM patients based at Seton Hall University’s School of Graduate Medical Education.(1) A low level of Mg leads to a low level of ATP, which is especially crucial in the brain, where 20 percent of the body’s ATP is stored, he explains.

Magnesium is also an essential in muscle metabolism and function. Among the high-profile researchers emphasizing the importance of sufficient Mg in the tissues of FM/CFS patients is Paul Cheney, MD, whose highly publicized recent research involves studies of the association between ATP production and abnormal heart function in CFS.

Blood tests alone don’t tell the whole Mg story, says Dr. Cheney, because they are not sensitive to intra-cellular magnesium.(1) “Magnesium, like potassium, is pumped into the cell, so [there should be] a higher concentration inside the cell than there is in the blood,” he explains. “And that pump mechanism may not work very well in people with CFS, so their magnesium levels can be normal in the blood and low in the cell.”

Studies have also shown that Mg inhibits many nerve receptors related to the origins of certain types of pain in FM patients. As a result, when Mg is deficient in the body, it is borrowed from muscle cells, and “calcium [moves] in to replace it, causing the muscles to grow stiff and tense,” writes Richard Firshein, DO, author of The Nutraceutical Revolution.(7)

While magnesium helps activate production of ATP, malic acid allows the body to make the ATP more efficiently, even under low oxygen, or “hypoxic” conditions.

Chemical analyses of tissues have identified low “oxygen pressure” in the muscles of many FM patients studied, and indicated that these patients’ “tender points” were often deficient in ATP.(1) Tender points are areas of muscle attachment to bone, ligaments, and tendons which may be painful when pressed in FM patients.

Jay Goldstein, MD – known for his CFS studies focused on disturbances in neurotransmitters, the chemical substances responsible for transmitting cell-to-cell information – indicated he found malic acid to be a safe, inexpensive nutritional supplement which he recommends for CFS and FM patients suffering continuing or recurring muscle soreness, discomfort, and fatigue.(8)

Other top CFS clinicians who recommend a combination of Mg and malic acid for improved quality-of-life measures include Dr. Cheney and Daniel L. Peterson, MD – who together earned their places in medical history by documenting the 1985 CFS outbreak in Incline Village, Nevada – and leading CFS clinician Dr. David Teitelbaum, as discussed in his book From Fatigued to Fantastic.(9)

In their 1999 book Making Sense of Fibromyalgia,(10) noted rheumatologist Daniel J. Wallace, MD, and Janice Brock Wallace cite controlled studies in England and Texas supporting the success of a proprietary combination of malic acid and magnesium in FM patients with recurring soreness or tenderness in the muscles. “If subjects take a dose larger than recommended on the bottle… its effects become apparent within a week.…and side effects are uncommon,” they note, referring to a study that started doses of magnesium at 300 mg and increased them until symptoms were reduced or side effects appeared. “This combination may work as a result of interactions between magnesium and calcium channels within muscles and the generation of adenosine triphosphate (ATP).”

Jorge Flechas, MD, MPh, an FM specialist in Hendersonville, ND, has participated in two studies that have tested a combination of malic acid and magnesium for pain and fatigue. In these studies, subjects diagnosed with Fibromyalgia reported a significant reduction in discomfort and tenderness within 48 hours and without any side effects. Specifically, he says, his experience with about 500 individuals who used this combination was that “the results are positive 90 percent of the time."(11)

Billie J. Sahley, PhD, a San Antonio-based nutritional specialist and author, has also reported improved energy and comfort with the Mg/malic acid combination for FM and CFS patients.(4) He reports prescribing doses ranging from 800 to 1200 mg per day, “using diarrhea as the limiting factor,” because “FM patients tend to be extremely low in magnesium… [and] the sooner malic acid and magnesium are started, the faster individuals begin to return to their normal lifestyles.”

Things to Know About Mg Supplementation

In addition to maintaining normal muscle and nerve function, “magnesium keeps heart rhythm steady, supports a healthy immune system, and keeps bones strong” by aiding with calcium absorption, according to a National Institutes of Health fact sheet.(12) “It also helps regulate blood sugar levels, promotes normal blood pressure, and is known to be involved in energy metabolism and protein synthesis. It is essential in the conversion of vitamin D to its biologically active form, which then helps the body absorb and utilize calcium.” And, especially important for CFS and FM patients, studies indicate that sleep deprivation is associated with low levels of magnesium in the red blood cells.(13)

The many sources of Mg range from milk and “hard” mineral-containing water to “sunshine” foods such as spinach, whole grains, and bananas. But with refined foods, magnesium-depleted soil, and the lack of Mg in commercial fertilizers, the vast majority of the U.S. population fails to obtain even 40 percent of the recommended dietary intake (RDI) of Mg from their diet, according to the USDA.(14)

A blood test may identify suboptimal Mg levels, though as noted this does not tell the whole story, since most of the body’s magnesium is found within the cell membranes and not in blood. The U.S. recommended RDI of Mg for an adult is 400 milligrams per day. Therapeutic doses used in clinical trials have typically been higher, ranging from 500 to 1500 mg per day, and “while many prescription medicines can cause side effects,” by comparison healthcare practitioners have found dietary magnesium supplements “extremely safe,” says Mg expert and author Alan R. Gaby, MD.(15)

Individuals with kidney disease are generally advised to avoid Mg supplementation. Anyone taking prescription or over-the-counter drugs should consult their doctor or a pharmacist: Certain diuretics, antibiotics, and other drugs may reduce Mg absorption. Laxatives and antacids often contain Mg. Diarrhea and loose stools are the most common side effects of Mg supplementation, and Mg “toxicity” is rare, as healthy kidneys excrete any reasonable excess.(16)


1. Go to ProHealth.com [1]to find a review summarizing the findings of 16 studies addressing Mg deficiencies in FM patients and benefits of supplementation, titled “Magnesium in the Treatment of Fibromyalgia,” by Georges Ramalanjaona, MD, DSc, FACEP, MBA, from Alternative Medicine Alert, March 2002.

2. Go to ProHealth.com [1]to find “A magnesium deficiency?” an abstract of “Review and hypothesis: Might patients with the Chronic Fatigue Syndrome have latent tetany of magnesium deficiency?” by Mildred Selig, MD, MPH, in the Journal of Chronic Fatigue Syndrome, Vol. 4, #2, 1998.

3. “NMR spectroscopy of muscle in Fibromyalgia Syndrome patients and sedentary controls,” R.W. Simms, et al., Arthritis and Rheumatism 1993.

4. Malic Acid and Magnesium for Fibromyalgia and Chronic Pain Syndrome, by Billie J. Sahley, PhD, Pain & Stress Therapy Center Publications, San Antonio 1995.

5. “Top CFIDS Researchers and Physicians Find Nutritional Supplement to Reduce Muscle Pain and Fatigue in Some Cases,” CFIDS Association of America, October 1994, ProHealth.com


6. “Magnesium and Malic Acid: Partners in Muscle Health,” by Molly Hozschlag, December 1, 1994; and “American College of Physicians on Malic Acid,", June 6, 2006.

7. “Magnesium’s Profound Effect on CFS,” by Richard Firshein, DO, from The Nutraceutical Revolution, Riverhead Books, 1998.

8. Betrayal by the Brain: The Neurologic Basis of Chronic Fatigue Syndrome, Fibromyalgia Syndrome, and Related Neural Network Disorders, by Jay Goldstein, MD, Haworth Medical Press, 1998.

9. From Fatigued to Fantastic, Dr. David Teitelbaum, Avery Penguin Putnam, 2001.

10. Dr. Wallace is Medical Director of the Wallace Rheumatic Study Center in Los Angeles, an Attending Physician at Cedars-Sinai Medical Center, and Clinical Professor of Medicine at UCLA’s David Geffen School of Medicine. He has written numerous books on “central pain syndromes.”

11. “Malic Acid and Magnesium for Fibromyalgia and Chronic Pain Syndrome,” by G.E. Abraham and J.D. Flechas, published in the March 1992 issue of the Journal of Nutritional Medicine, archived at http://www.immunesupport.com/message/malic.htm [2]

12. NIH Clinical Center, Office of Dietary Supplements, at dietary-supplements.info.nih.gov/factsheets/magnesium.asp [3]

13. “Erythrocyte magnesium and prostaglandin dynamics in chronic sleep deprivation,” K. Tanabe, et al., Clinical Cardiology, March 1997.

14. “Percentage of Individuals Meeting DRI – Magnesium” by state, USDA Community Nutrition Research Service site, at www.ba.ars.usda.gov/cnrg/services/magnesium.html

15. “Magnesium is the Missing Link in Many Chronic Ills,” from Magnesium, by Alan R. Gaby, MD, Keats Publishing, 1994.

16. Drug-Induced Nutrient Depletion Handbook, 2nd Edition, by Ross Pelton, RPh, PhD, CCN, et al., Lexi-Comp, Inc., 2001.