Orthostatic hypotension, colloquially known as head rush or dizzy spell, is a form of low blood pressure in which a person's blood pressure falls when suddenly standing up or stretching. In medical terms, it is defined as a fall in systolic blood pressure of at least 20 mm Hg or diastolic blood pressure of at least 10 mm Hg when a person assumes a standing position.
When orthostatic hypotension is present, the following symptoms can occur after sudden standing or stretching (after sitting):
- Euphoria or dysphoria
- Bodily dissociation
- Distortions in hearing
- Temporary decrease in hearing
- Blurred or dimmed vision (possibly to the point of momentary blindness)
- Generalized (or extremity) numbness/tingling and fainting
- Coat hanger pain (pain centered in the neck and shoulders)
- And in rare, extreme cases, vasovagal syncope (a specific type of fainting).
They are consequences of insufficient blood pressure and cerebral perfusion (blood supply). Occasionally, there may be a feeling of warmth in the head and shoulders for a few seconds after the dizziness subsides. The drop in blood pressure may cause a vasovagal episode to occur.
Orthostatic hypotension is caused primarily by gravity-induced blood-pooling in the lower extremities, which in turn compromises venous return, resulting in decreased cardiac output and subsequent lowering of arterial pressure. For example, changing from a lying position to standing loses about 700 ml of blood from the thorax, with a decrease in systolic and diastolic blood pressures. The overall effect is an insufficient blood perfusion in the upper part of the body.
Still, the blood pressure does not normally fall very much, because it immediately triggers a vasoconstriction (baroreceptor reflex), pressing the blood up into the body again. (Often, this mechanism is exaggerated and is why diastolic blood pressure is a bit higher when a person is standing up, compared to a person in horizontal position.) Therefore, a secondary factor that causes a greater than normal fall in blood pressure is often required. Such factors include low blood volume, diseases, and medications.
Orthostatic hypotension may be caused by low blood volume, resulting from bleeding, the excessive use of diuretics, vasodilators, or other types of drugs, dehydration, or prolonged bed rest. It also occurs in people with anemia.
The disorder may be associated with Addison's disease, atherosclerosis (build-up of fatty deposits in the arteries), diabetes, pheochromocytoma, and certain neurological disorders, including multiple system atrophy and other forms of dysautonomia. It is also associated with Ehlers-Danlos syndrome and Anorexia Nervosa. It is also present in many patients with Parkinson's disease resulting from sympathetic denervation of the heart or as a side-effect of dopaminomimetic therapy. This rarely leads to fainting unless the person has developed true autonomic failure or has an unrelated heart problem.
Another disease, dopamine beta hydroxylase deficiency, also thought to be underdiagnosed, causes loss of sympathetic noradrenergic function and is characterized by a low or extremely low levels of norepinephrine, but an excess of dopamine.
Quadriplegics and paraplegics also might experience these symptoms due to multiple systems' inability to maintain a normal blood pressure and blood flow to the upper part of the body.
Orthostatic hypotension can be a side-effect of certain antidepressants, such as tricyclics or monoamine oxidase inhibitors (MAOIs). Marijuana and tetrahydrocannabinol can on occasion produce marked orthostatic hypotension. Orthostatic hypotension can also be a side effect of Alpha-1 blockers (alpha1 adrenergic blocking agents). Alpha1 blockers inhibit vasoconstriction normally initiated by the baroreceptor reflex upon postural change and the subsequent drop in pressure.
Orthostatic hypotension sometimes is a reversible neurological complication of vitamin B12 deficiency.
The use of a safety harness does not contribute to orthostatic hypotension in the event of a fall. This notion is a hypothetical risk which has all but been eliminated due to modern design and safety regulations. If worn properly, a safety harness may safely rescue its user from a fall without any further complications so long as the individual does not remain suspended for prolonged periods of time.
Patients prone to orthostatic hypotension are the elderly, post partum mothers, and those having been on bedrest. People suffering from anorexia nervosa and bulimia nervosa often suffer from orthostatic hypotension as a common side-effect. Consuming alcohol may also lead to orthostatic hypotension due to its dehydrating effects.
Stand up slowly if there is a risk of hypotension.
There is a simple test for OH that measures the person's blood pressure after lying flat for 5 minutes, then 1 minute after standing, and 3 minutes after standing. Orthostatic hypotension is defined as a fall in systolic blood pressure of at least 20 mmHg and/or in the diastolic blood pressure of at least 10 mmHg between the supine reading and the upright reading. In addition, the heart rate should also be measured for both positions. A significant increase in heart rate from supine to standing may indicate a compensatory effort by the heart to maintain cardiac output or Postural Orthostatic Tachycardia Syndrome (POTS). A tilt table test may also be performed.
While mild forms of orthostatic hypotension may be a nuisance, more-serious complications are possible, especially in older adults. These complications include:
- Falls. Falling down as a result of fainting (syncope) is a common complication in people with orthostatic hypotension.
- Stroke. The swings in blood pressure when you stand and sit as a result of orthostatic hypotension can be a risk factor for stroke due to the reduced blood supply to the brain.
- Cardiovascular diseases. Orthostatic hypotension can be a risk factor for cardiovascular diseases and complications, such as chest pain, heart failure or heart rhythm problems.
The treatment for orthostatic hypotension depends on the underlying cause. Your doctor will try to address the underlying health problem — dehydration or heart failure, for example — rather than the low blood pressure itself.
For mild orthostatic hypotension, one of the simplest treatments is to sit or lie down immediately after feeling lightheaded upon standing. Your symptoms of orthostatic hypotension usually disappear.
When low blood pressure is caused by medications, treatment usually involves changing the dose of the medication or stopping it entirely.
Several medications, either used alone or together, can be used to treat orthostatic hypotension. For example, the drug fludrocortisone is often used to help increase the amount of fluid in your blood, which raises blood pressure. Doctors often use the drug midodrine (ProAmatine) to raise standing blood pressure levels. It works by limiting the ability of your blood vessels to expand, which in turn raises blood pressure.
Droxidopa (Northera) may be prescribed to treat orthostatic hypotension associated with Parkinson's disease, multiple system atrophy or pure autonomic failure.
Other medications, such as pyridostigmine (Regonol, Mestinon), nonsteroidal anti-inflammatory drugs (NSAIDs), caffeine and epoetin (Epogen, Procrit), are sometimes used, too, either alone or with other medications for people who aren't helped with lifestyle changes or other medications.
Refer to Research Publications.