Orthostatic Hypotension

Orthostatic hypotension is a sudden drop in blood pressure that happens when you stand up from sitting or lying down. This condition can make you feel dizzy or lightheaded, and sometimes even cause you to faint. While it can affect anyone, it becomes more common with age and can significantly impact daily life.

Table of contents

• What Is Orthostatic Hypotension
• Signs and Symptoms
• Who Is Affected
• What Causes This Condition
• How It Is Diagnosed
• Treatment Options
• Health Risks and Complications

postural hypotension

What Is Orthostatic Hypotension

Orthostatic hypotension, also called postural hypotension, is a form of low blood pressure that occurs when you change position from sitting or lying down to standing^[1]. The condition is officially defined as a drop in systolic blood pressure (the top number in a blood pressure reading) of at least 20 millimeters of mercury (mm Hg), or a drop in diastolic blood pressure (the bottom number) of at least 10 mm Hg within three minutes of standing up^[2].

When you stand up, gravity naturally pulls blood down into your legs and lower body. In healthy people, the body quickly adjusts by making the heart beat faster and tightening blood vessels to maintain normal blood flow to the brain. However, in people with orthostatic hypotension, these automatic adjustments either don’t work properly or don’t happen fast enough^[3].

This condition can be either acute (short-term) or chronic (long-lasting). Some people experience only brief episodes, while others deal with ongoing symptoms that require management^[1].

Signs and Symptoms

The most common symptom of orthostatic hypotension is feeling lightheaded or dizzy when you stand up after sitting or lying down^[1]. These symptoms usually last less than a few minutes and improve when you sit or lie back down^[3].

Symptoms tend to be worse in the morning because blood pressure is normally at its lowest when you first wake up. Hot temperatures, whether from weather, fever, or even a hot shower or bath, can also make symptoms worse^[3].

Common symptoms include:

• Lightheadedness or dizziness upon standing
• Blurred vision
• Weakness or fatigue
• Fainting (called syncope)
• Confusion or difficulty concentrating
• Nausea or feeling hot and sweaty
• Headaches
• Heart palpitations (feeling your heart beating)
• Chest pain, shoulder pain, or neck pain
• Shortness of breath

Some people describe a specific type of pain in the neck and shoulders, called “coat hanger pain,” which can occur during episodes^[7]. Interestingly, many people with orthostatic hypotension don’t experience any symptoms at all, and the condition may only be discovered during routine medical testing^[7].

Who Is Affected

Orthostatic hypotension affects approximately 20% of people over age 65, making it particularly common in older adults^[3]. In middle-aged adults, only about 5% are affected^[4]. The condition is even more prevalent in certain settings—more than 50% of elderly people living in long-term care facilities may have orthostatic hypotension^[5].

Several factors increase your risk of developing this condition^[3]:

• Increasing age
• Anemia or vitamin B12 deficiency
• Dehydration from diarrhea, vomiting, or diuretics (water pills)
• Endocrine problems, including diabetes, thyroid disease, and Addison disease
• Heart conditions, including irregular heart rhythms and heart valve disease
• Medications for high blood pressure, heart disease, and depression
• Neurological problems, such as Parkinson disease and dementia
• Pregnancy, especially during the first 24 weeks
• Prolonged bed rest due to illness

The condition is also common among people who have recently given birth or are recovering from illness. Even teenagers experiencing growth spurts can sometimes have orthostatic hypotension^[3].

What Causes This Condition

Orthostatic hypotension occurs when the body cannot properly adjust blood pressure after standing up. When you stand, 300 to 800 milliliters of blood pools in your lower body^[4]. Normally, your autonomic nervous system—the part of your nervous system that controls involuntary body functions—responds by constricting blood vessels and increasing heart rate to maintain steady blood flow to your brain and other organs^[2].

The condition can be broadly classified as neurogenic or non-neurogenic depending on the underlying cause^[2].

Neurogenic orthostatic hypotension occurs when there are problems with the autonomic nervous system. This can happen with conditions that affect nerve function, including Parkinson disease, dementia with Lewy bodies, multiple system atrophy, diabetic nerve damage (neuropathy), or infections affecting nerves^[7].

Non-neurogenic orthostatic hypotension is often caused by factors that don’t directly involve nerve damage. Common causes include^[6]:

• Dehydration or low blood volume
• Heart disease or heart valve problems
• Extremely low heart rate (called bradycardia)
• Advanced age
• Alcohol use
• Certain medications

Many medications can contribute to orthostatic hypotension, including drugs used to treat high blood pressure (such as diuretics, beta-blockers, and calcium channel blockers), medications for Parkinson disease, drugs for erectile dysfunction, some antidepressants and antipsychotics, and muscle relaxants^[6].

Eating large meals can also trigger a form of this condition called postprandial hypotension, where blood pressure drops after eating because the digestive system needs extra blood^[6].

How It Is Diagnosed

The diagnosis of orthostatic hypotension begins with measuring blood pressure and heart rate in different positions. The standard test involves measuring blood pressure after lying down for at least five minutes, then again after standing for three minutes^[9]. The diagnosis is confirmed if systolic blood pressure drops by 20 mm Hg or more, or diastolic blood pressure drops by 10 mm Hg or more^[2].

Your healthcare provider will also review your medical history, current medications, and symptoms. They may conduct a physical examination to help identify the underlying cause^[14].

Additional tests may include^[14]:

• Blood tests to check for anemia, low blood sugar, or other conditions
• Electrocardiogram (ECG or EKG) to measure the heart’s electrical activity
• Echocardiogram to create pictures of the heart using sound waves
• Holter monitor to record heart activity over a day or more

If symptoms suggest orthostatic hypotension but the bedside test is normal, or if a patient cannot stand safely, your doctor may recommend head-up tilt table testing. During this test, you lie on a special table that tilts to at least 60 degrees, allowing blood pressure to be monitored in a controlled way^[2].

It’s important to note that measuring heart rate along with blood pressure helps determine whether the cause is neurogenic. In neurogenic orthostatic hypotension, the heart rate typically doesn’t increase much despite the blood pressure drop, while in non-neurogenic causes, the heart rate usually increases significantly^[11].

Treatment Options

The main goal of treatment is to reduce symptoms and improve quality of life, rather than simply normalizing blood pressure. Treatment focuses on identifying and addressing the underlying cause, making lifestyle changes, and when necessary, using medications^[11].

Non-Medication Approaches

Non-medication strategies should always be tried first and are essential even when medications are needed^[11]. These approaches include:

Changing positions slowly: When getting up, move gradually. If you’re in bed, first roll to your side, then sit on the edge of the bed for a while before slowly standing up^[16].

Increasing fluids and salt: Drinking plenty of water and adding more salt to your diet (if your doctor approves) can help increase blood volume. Drinking about 16 ounces of water can increase blood pressure for several hours^[13].

Dietary changes: Eating smaller, more frequent meals instead of large ones can help prevent postprandial hypotension. Reducing carbohydrate intake and limiting or avoiding alcohol are also recommended^[13].

Physical strategies: Wearing compression stockings or abdominal binders can help prevent blood from pooling in the legs. Physical countermaneuvers, such as tensing leg and abdominal muscles or crossing legs while standing, can help maintain blood pressure^[13].

Elevating the head of the bed: Sleeping with the head of your bed raised 10 to 20 degrees can help reduce symptoms in the morning^[18].

Staying active: Regular exercise, particularly activities that strengthen leg muscles, can improve blood flow and reduce symptoms^[18].

Medication Treatment

If non-medication approaches aren’t enough, several medications can help^[12]:

Midodrine is often considered a first-line medication. It works by constricting blood vessels to increase blood pressure. Studies show it effectively improves symptoms and standing blood pressure^[11].

Droxidopa is another first-line option that helps the body produce norepinephrine, a chemical that raises blood pressure. It’s particularly helpful for people with neurogenic orthostatic hypotension^[12].

Fludrocortisone helps the kidneys retain salt and water, increasing blood volume. While it can improve symptoms, there are concerns about its long-term effects^[11].

Pyridostigmine works by enhancing signals from the nervous system and may be helpful, particularly when combined with midodrine^[12].

Your doctor will work with you to find the most appropriate treatment based on the underlying cause of your orthostatic hypotension, other medical conditions you may have, and your current medications^[12].

Health Risks and Complications

Orthostatic hypotension is associated with significant health risks. The most immediate danger is falling, which can lead to serious injuries, especially in older adults. Falls related to this condition often result in hospital admissions^[2].

Beyond falls, orthostatic hypotension is linked to several serious health problems. The condition increases the risk of cardiovascular disease, including heart attack, heart failure, and irregular heart rhythms such as atrial fibrillation^[7].

Repeated episodes of low blood pressure can reduce blood flow to vital organs. This can increase the risk of stroke, dementia, and chronic kidney failure^[7]. Research shows that orthostatic hypotension is associated with up to a 50% increase in the relative risk of death from any cause^[2].

One particularly challenging complication is supine hypertension—high blood pressure while lying down—which affects many people with neurogenic orthostatic hypotension. This makes treatment more difficult because medications that raise blood pressure when standing can make lying-down blood pressure dangerously high^[11].

It’s important to seek medical attention if you frequently feel lightheaded when standing up, or if you’ve experienced fainting episodes. Even brief losses of consciousness should be evaluated by a healthcare provider^[1]. Keeping a record of your symptoms, including when they occur, how long they last, and what you were doing at the time, can help your doctor understand and treat your condition more effectively.