Orthostatic Intolerance (OI) Symptoms:
The Symptoms That Come First - Start with Standing Upp

The symptoms for fainting, POTS (Postural ORthostatic Tachycardia Syndrome), orthostatic hypotension (OH), neurally-mediated hypotension (NMH) are similar. Not all of the symptoms start right away. OI symptoms can be different depending on when they start after a person stands up.
    •  Symptoms that start before the faint - The first set is the classic symptoms a person gets before they faint - dizziness or a lightheaded feeling, vision changes, weakness.
    •  Symptoms that come if you continue to stand and you haven't fainted - If a person continues to stand up, more symptoms can develop - the "prolonged prodrome".
    •  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.
    •  Other symptoms - There are also symptoms that can develop that are associated with failure of the autonomic nervous system.

The First Symptoms That Come Before the Faint and With Standing Longer

There are 2 types of symptoms that develop when a person with OI changes body position. The orthostatic symptoms can start when a person goes from lying down to standing up or from sitting to standing up.1-8. 10-12

One reason the symptoms start is the person is not getting enough blood to the organs, especially the head, when they stand up. The longer they stand, the longer the blood flow is not getting to the organs at the top. Generally, the symptoms start to go away once the person sits down or lies down - but more symptoms may start after fainting, standing up or sitting up.

Classic Warning Symptoms Before the Faint! (Prodromal)
Prolonged Symptoms - Symptoms that come with continuing to stand up
  • Dizziness, lightheadedness. Also described as "head rush" or "whoosh"
  • Nausea
  • Vision: blurring, darkness, tunnel, spots
  • Hearing: sounds seem distant, ringing in ears
  • Clamminess/sweating
  • Weakness
  • Palpitations
  • Short of breath
  • Face pain/TMJ pain
  • Headache - back of head, neck, upper shoulders ("coat hanger" headache)3,9
  • Chest pressure/discomfort
  • Low back pain4
  • Tremulousness5,6,7,8 (Shakiness)
  • Anxiety
  • Flushing after meals5, bloating, abdominal pain, pain after eating (postprandial angina)5
  • Blueness in the feet and lower legs (acrocyanosis)5,8
  • Sleep disorder6
  • Nerve pain5,6,7,8
  • Mental fog - slowness in thinking, trouble finding words, substituting words, trouble with simple math
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Positions besides standing up that can cause symptoms

Sitting up with the feet on the floor can also cause orthostatic symptoms in a person with moderate to severe orthostatic intolerance.
Sitting up    If a person has been in bed or is bed bound, the orthostatic symptoms of dizziness, vision, headaches, etc., can come when they sit up in bed.

Symptoms that come later - after the faint, after standing up for awhile

There are more symptoms that go with fainting or standing up but not all symptoms come right away and go away by lying down. The lack of good blood flow to the head and rest of the body creates delayed symptoms. These delayed symptoms that can come and last for hours or they can last for days.

Delayed Symptoms


Some of the symptoms listed above are commonly described with fainting or orthostatic problems. They are described in the general references. We have not listed each of the general references after each of those symptoms. They are listed below as "general references" which are marked with *.

Other symptoms are described in other articles and are often cited in blogs and forums by patients with POTS. The reference for those symptoms are separately listed.

  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: August 17, 2012