Common Triggers of Orthostatic Symptoms

Things that trigger or make orthostatic symptoms worse standing up are also called "Orthostatic Stressors". They are known to trigger orthostatic symptoms even in someone who has been pretty stable. They can also make orthostatic symptoms worse. These are things to avoid when possible. . The person with POTS, NMH, or other types of orthostatic intolerance syndromes probably already knows some of them and already avoids them whenever possible.

These are things to either avoid if possible. If you can't avoid them, then the challenge is to figure out things to do that will help control how much they affect your orthostatic problem.

The most common things that trigger or worsen orthostatic symptoms:
  • Not getting in enough fluids AND salt
  • Hot weather. especially if it is also humid or getting hot
  • Menstrual cycle – for some women
  • Vigorous exercise
  • Prolonged bedrest2-6
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Things that you do
  • Standing still for long periods of time (Prolonged motionless standing)
  • Sitting still at a desk for a long time with your feet down
  • Eating a big meal, especially if you try to do things afterwards that are standing up
  • Physical exertion, especially vigorous activity
  • Rising quickly after sitting or lying down for a long time
  • Things that increase pressure in the abdomen
    • Coughing spell
    • Straining – to go to the bathroom for urine or defecate (have a bowel movement, BM, stool)
    • Isometric exercises – people tend to hold their breath when they do them
    • Laughing really hard and long3
Things in your daily life
  • Stress
  • Exercise - standing up when your body has not been re-trained
  • Emotionally stressful events – like seeing blood or a gory scene, being scared (triggers ‘fight or flight or freeze’)
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Things about your body
  • Time of day  - OI is worse in early morning
  • Fever
  • Varicose veins- if severe, they can hold large amounts of blood
  • Low blood sugar (hypoglycemia)
  • Hyperventilation3
  • Pain
Things you eat or take as medications
  • Alcohol ingestion (alcohol dilates veins - more pooling)
  • Niacin (in doses more than the recommended daily amount)
  • Carbohydrate-heavy meals (eating shifts blood to the vessels around the stomach/intestines)
  • Albuterol – inhaler for asthma, COPD, allergic reactions
  • Epinephrine (adrenaline)(could be used to treat allergic reaction, e.g. to bee sting)
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  1. Figueroa JJ, Basford JR, Low PA. Preventing and treating orthostatic hypotension: As easy as A, B, C. Cleve Clin J Med. 2010 May;77(5):298-306.  Abstract.  Article PDF.
  2. Freeman, Roy. Neurogenic orthostatic hypotension.NEJM 2008;358(6):615-624. Abstract #90
  3. 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. #103
  4. Low PA, Sandroni P, Joyner and Shen W. Postural Tachycardia Syndrome (POTS). J Cardopvasc Electrophysiology 2009; 20:352-358.  Abstract.  Article PDF
  5. Rowe, Peter.  General Information Brochure on Orthostatic Intolerance and Its Treatment. June 2010. Accessed from http://www.cfids.org/webinar/cfsinfo2010.pdf. Accessed May 28.2012.
  6. Rowe, Peter. Managing Orthostatic Intolerance. Webinar. September 1, 2010. Hosted by CFIDS Association of American. Accessed June 1, 2012.  Written material.  Slides PDF.   Video.

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