Delayed Symptoms

There are more symptoms that develop after standing up/lying back down They are caused by the orthostatic problem but they are not as obvious. They start later and last a lot longer. Fatigue is probably one of the most common and debilitating of the delayed symptoms.

Standing or Sitting Up Is 'The Orthostatic Event'

After Fainting:    If a person has fainted, the faint is usually short. It comes on quickly. The person faints and then regains consciousness within 1-2 minutes5. They are often tired afterward. The fatigue can last an hour or a day.

After an Orthostatic Event with other types of orthostatic problems (NMH or POTS):    The "event" with these conditions is as simple as standing up for a long time. The change in blood pressure (BP) or pulse change can last much longer than a couple of minutes. For example, with POTS, the person starts to develop symptoms over 3-10 minutes. The orthostatic-type symptoms could last as long as the person stands and the pulse continues to be high.

Afterward standing for longer periods, the person may have a different type of symptoms. The delayed symptoms can last for hours and even days. The challenge in understanding the delayed symptoms is the fact that if a person's not on medication or stable with other management, every time a person stands up, they are releasing Epi/Norepinephrine and stressing the body. This starts a new set of delayed symptoms or makes them worse.

Symptoms That Start After the Faint or Standing Up

The delayed symptoms after a faint or orthostatic event or symptoms a person might experience on a daily or cyclical basis:

  • Fatigue - This could be mild to 'tired to the bone' fatigue. It can last hours or days. Chronic fatigue is often one of the biggest reasons a person goes to the physician. If a person also has Chronic Fatigue Syndrome (CFS), the chronic fatigue can be even more intense.

  • Mental fog - This might start while a person is standing up for awhile. But it continues if the person continues to stand up. A person might have confusion, problem with finding words, word-letter substitution, problem doing simple math, & memory problems.

  • Exercise Intolerance - This usually means the person cannot exercise like before getting sick. There is usually more fatigue after exercising. There might be orthostatic symptoms with exercising such as headache/neck pain, shortness of breath (hard to breath), or just feel "yucky". Just going up a flight of steps can bring symptoms.

  • Post-Exertional Malaise (PEM) - This is the fatigue and other symptoms including a general "yucky" feeling that comes after doing too much. It could come after climbing stairs, doing exercise, being in the heat for a long time or doing mental activities like reading, concentrating on paperwork, focusing on a computer screen. This relationship is especially obvious in people who have both POTS and CFS.16

  • Sleep disturbance - The sleep problem is often rearranged hours of sleeping and waking. Often, a person is lying in bed, even in the dark with no sounds, no TV, no music. It does not mean the person is asleep. They can be vey sensitive to sounds and light and just be resting. If you whisper, 'are you awake', you may be surprised. Also, sometimes, if they are very very fatigued, they do not have enough energy to answer. A signal can help - like 'raise 1 finger for yes' and '2 fingers mean no'.

  • Migraine headaches - Migraines can be a stressor and trigger orthostatic problems. Orthostatic problems that are not under control can also trigger more migraines.


Severity of Symptoms & Their Effect on Daily Life

These symptoms can be severe enough that they interfere with being able to be up standing to do daily care, like washing your face, showering, cooking, or doing laundry etc. or sitting up in a chair for long periods of time.

What Happens If You Keep Standing Up and Doing Things?

Trying to do things standing up when the orthostatic problem has not been corrected or treated will make the problem worse - the delayed symptoms will continue, get more intense or get more of them, and last longer.

Walking and Talking - Sometimes, if a person is having orthostatic problems but has to be up walking anyway, sometimes you can ask them a question and they don't answer.

It might be because:
     — You can think they didn't hear you,
     — they are purposely ignoring you,
     — they have a lot of mental fog and it is taking a long time for them to process your question and create an answer OR
     — they are short of breath and don't have any extra breath to talk. (This is the reason more than you might realize as a caregiver, family or friend.)


Don't see all your symptoms in the lists of Starting or Delayed Symptoms?

Check out the next list - Other Symptoms

  1. Moya, Guidelines for the diagnosis and management of syncope (version 2009). European Heart Journal (2009); 30: 2631-2671.  Abstract. Article PDF.
  2. Jacob G, Costa F, Shannon JR, Robertson RM et al. The Neuropathic Postural Tachycardia Syndrome. N Engl J Med 2000;343: 1008-14.  Abstract.   Article PDF.
  3. Freeman, Roy. Neurogenic orthostatic hypotension.NEJM 2008;358(6):615-624 Abstract
  4. Brignole, M. The syndromes of orthostatic intolerance. E-journal of Cardiology Practice. 2007: 6(5).Access.http://www.escardio.org/communities/councils/ccp/e-journal/volume6/Pages/vol6n5.aspx
  5. Medow MS, Stewart JM, Sanyal S, Mumtaz A, Stca D and Frishman WH. Pathophysiology, Diagnosis, and Treatment of Orthostatic Hypotension and Vasovagal Syncope. Cardiology in Review 2008;16(1):4-20. Abstract
  6. Soliman, K., Sturman, S., Sarkar, PK, Michael, M. Postural Orthostatic tachycardia Syndrome (POTS): A Diagnostic Dilemma. Br J Cardiol.2010: 17(1);36-39.
  7. Low PA and Singer W.  Update on Management of Neurogenic Orthostatic Hypotension. Lancet Neurol. 2008 May ; 7(5): 451–458. Abstract. Article PDF.
  8. Rowe, Pete. General Information Brochure on Orthostatic Intolerance and Its Treatment. June 2010. Accessed from http://www.cfids.org/webinar/cfsinfo2010.pdf. Accessed May 28.2012.
  9. Robertson D, Kincaid DW, Haile V, Roberston RM.The head and neck discomfort of autonomic failure: an unrecognized aetiology of headache. Clin Autonom Res. 1994: 4; 99-103
  10. Low PA, Sandroni P, Joyner M, Shen WK. Postural Tachycardia Syndrome (POTS). J Cardiovasc Electrophysiol. March 2009: 20; 352-358.
  11. Grubb BP. Postural tachycardia syndrome. Circulation. 2008;117:2814–2817. Abstract. Article PDF.
  12. Thieben MJ, Sandroni P, Sletten DM, et al. Postural orthostatic tachycardia syndrome: The Mayo Clinic experience. Mayo Clin Proc. 2007;82:308–313. Abstract. Article PDF.
  13. Sullivan SD, Hanauer J, Rowe PC, Barron DF, Darbari A, Oliva-Hemker M. Gastrointestinal symptoms associated with orthostatic intolerance. J Pediatr Gastroenterol Nutr. 2005 Apr;40(4):425-8. Abstract.
  14. Gordon, Victor. Assessment of the Autonomic Nervous System in Patients with Neuropathies. Presentation. Faculty of Pain Medicine. Autonomic laboratory, Melbourne Victoria. Assessed July 6, 2012.
  15. Johnson JN, Mack KJ, Kuntz NL, Brands CK, Porter CJ and Fischer PR. Postural Orthostatic Tachycardia Syndrome: A Clinical Review. Pediatr Neuro 2010; 42:77-85. Abstract.
  16. Capuron L, Welberg L, Heim C, Wagner D, Solomon L, Papanicolaou DA, Craddock RC, Miller AH, Reeves WC. Cognitive dysfunction relates to subjective report of mental fatigue in patients with chronic fatigue syndrome. Psychosom Med. 2008 Sep;70(7):829-36. Epub 2008 Jul 7.Abstract.  Article PDF.

Author: Kay E. Jewell, MD
Page Last Updated: September 5, 2012