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Light-headedness (near syncope) is a sense that one is about to faint. Fainting (syncope) is a sudden, brief loss of consciousness during which the person falls to the ground or slumps in a chair followed by a return to consciousness. The person is motionless and limp and usually has cool legs and arms, a weak pulse, and shallow breathing. Some people feel light-headed or dizzy before they faint. Others may have nausea, sweating, blurred or tunnel vision, tingling of lips or fingertips, chest pain, or palpitations. Less often, people faint suddenly, without any warning symptoms. Seizures, which are a disturbance of the brain's electrical activity, and cardiac arrest, in which the heart completely stops beating, can cause loss of consciousness but are not considered fainting.
Fainting can occur in people of any age, but dangerous causes of fainting are more common among older people.
Causes
A person cannot lose consciousness unless brain function is generally disturbed. This disturbance usually occurs because overall blood flow to the brain is reduced. Sometimes, however, blood flow is adequate but the blood does not contain sufficient oxygen or glucose (blood sugar), which the brain needs to function.
Blood flow to the brain can be reduced in several ways. Most often, the cause is something that interferes with the normal return of blood to the heart (and thus reduces blood flow out from the heart). Less often, the cause is a disorder that interferes with blood pumping (typically a heart disorder). Although strokes reduce blood flow to the brain, they only reduce flow to part of the brain. Thus, strokes rarely cause fainting except for the few strokes that involve the part of the brain that maintains consciousness.
The most common causes are
These common causes nearly always cause fainting only when people are standing up. When they fall down, blood flow to the brain is increased, quickly restoring consciousness, although people may not feel completely normal for a few minutes. Some people feel tired or exhausted for several hours. These causes tend not to be serious unless people are injured when they fall.
Most of these causes involve decreased return of blood to the heart. Strong emotion (particularly that triggered by the sight of blood) or pain can activate the vagus nerve. Vagus nerve activation widens blood vessels, reducing the return of blood to the heart, and slows the heart rate. Both of these factors cause light-headedness and sometimes fainting (called vasovagal syncope).
Straining during bowel movements or urination or coughing increases chest pressure. Increased chest pressure can activate the vagus nerve and also reduce the return of blood to the heart—two factors that may cause fainting.
Healthy people may faint when standing still for a long time (most common in soldiers, a phenomenon called parade ground syncope), because the leg muscles have to be active to help return blood to the heart.
Sitting or standing up too quickly can cause fainting, because the change in position causes blood to pool in the legs, resulting in a fall in blood pressure. Normally, the body quickly increases the heart rate and constricts blood vessels to maintain blood pressure (see High Blood Pressure: The Body's Control of Blood Pressure). If the body does not compensate in these ways, light-headedness is common and fainting may rarely occur. Certain brain and spinal cord disorders, prolonged bed rest, and certain drugs (particularly those used to treat high blood pressure) can interfere with this compensation and lead to fainting when standing up (see Symptoms of Heart and Blood Vessel Disorders: Dizziness or Light-Headedness When Standing Up).
Hormonal changes in early pregnancy sometimes lead to fainting.
Low blood sugar (hypoglycemia) initially causes confusion, light-headedness, shakiness, and other symptoms, but if hypoglycemia is severe or prolonged, people can lose consciousness. Because these other symptoms usually occur before fainting, people with hypoglycemia usually have some warning before they faint. Usually, the cause of hypoglycemia is use of drugs for diabetes, particularly insulin. Rarely, people have a tumor that secretes insulin.
Less common but more serious causes include
Heart valve disorders can block blood from leaving the heart. A very fast heart rate may not allow the heart enough time to refill with blood, so less blood is pumped. A very slow heart rate may not pump enough blood. Blood clots in the lungs can keep the heart from pumping enough blood. People with a heart attack rarely have fainting when the heart attack occurs (more common in older people). Other uncommon heart muscle disorders called cardiomyopathies can cause fainting, particularly during exercise, typically because of an abnormal heart rhythm.
Although most strokes do not cause fainting, a stroke or transient ischemic attack (TIA) that involves certain blood vessels at the base of the brain (posterior circulation stroke) can cause fainting. Similarly, a migraine that involves these blood vessels sometimes causes fainting.
Evaluation
If possible, someone who witnessed the faint should provide the doctor with a description of the event because the person who fainted may not remember.
Warning signs:
In people who have fainted, certain symptoms and characteristics are cause for concern. They include
When to see a doctor:
Although most causes of fainting are not serious, a doctor's evaluation is needed to distinguish serious causes from relatively harmless ones. People who fainted should see a doctor right away, especially if they have any warning signs.
What the doctor does:
Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What doctors find during the history and physical examination often suggests a cause of the fainting and the tests that may need to be done.
Doctors ask about the events leading up to the fainting episode. They ask whether the person was exercising, arguing, or in a potentially emotional situation. They ask whether the person was lying or standing, and, if standing, for how long. They also ask about symptoms that occurred immediately before or after the event, including whether the person felt light-headed or dizzy or experienced nausea, sweating, blurred or tunnel vision, tingling of lips or fingertips, chest pain, or palpitations. Doctors also ask any witnesses to describe the episode. A sudden, abrupt faint without any warning symptoms or apparent trigger suggests a heart disorder. If fainting is preceded by a brief period of symptoms such as light-headedness, nausea, yawning, blurred vision, or sweating and occurs during a painful or unpleasant situation, it is probably vasovagal syncope, which is not dangerous.
Doctors ask about previous episodes of dizziness or fainting and about other disorders, drugs, or symptoms that may be related to fainting. Doctors also check the person for injuries resulting from the fainting episode.
Then doctors measure the person's vital signs. Heart rate and blood pressure are measured with the person lying down and after 2 minutes of standing. Doctors listen to the heart for signs of an abnormal heart valve or abnormal blood flow. They do a neurologic examination for signs of a stroke.
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Some Causes and Features of Fainting |
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Cause
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Common Features*
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Tests†
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Serious causes
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Heart valve disorders, such as aortic or mitral stenosis or failure of an artificial heart valve
Cardiomyopathy (disorders affecting heart muscle), particularly hypertrophic cardiomyopathy
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Fainting during or after exercise, followed by a prompt recovery
In young or old people
Often in people who are known to have had a heart murmur
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Echocardiography (ultrasonography of the heart)
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A very slow heart rate (typically less than 35 beats per minute), more common in older people
A very rapid heart rate (typically over 150 beats per minute)
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Fainting without warning, followed by recovery immediately after awakening
Fainting that may occur in any position
Sometimes in people taking certain drugs, especially drugs used to treat heart disorders such as abnormal heart rhythms (antiarrhythmic drugs)
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ECG, sometimes continuous ambulatory ECG (using a Holter monitor worn for 24 hours or, rarely, a recording device or implanted under the skin)
Sometimes blood tests to measure electrolytes such as sodium and potassium
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Pulmonary embolsim (blockage of an artery to the lungs by a blood clot )
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Often sharp pain when breathing in, shortness of breath, rapid breathing, and a rapid heart rate
Sometimes mild fever, coughing up blood, or shock
More likely in people with risk factors for pulmonary embolism (such as previous blood clots, recent surgery especially surgery on the legs, prolonged bed rest, a cast or splint on a leg , older age, smoking, or cancer)
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CT or nuclear scanning of the lungs
A blood test to detect blood clots (d-dimer test)
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Heart attack (myocardial infarction)
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Usually in older people
Sometimes chest discomfort, feeling of indigestion, shortness of breath, or nausea
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ECG
Blood tests to measure substances that indicate heart damage (cardiac markers)
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A severe allergic reaction (anaphylaxis) causing very low blood pressure
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Fainting during or shortly after being exposed to a trigger for an allergic reaction, such as a drug or an insect bite
Excessive sweating and pale skin color
In people who may or may not have a history of allergies
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Allergy testing
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A low blood sugar level (hypoglycemia)
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Fainting after a period of other symptoms, including confusion, shakiness, and sweating
Unresponsiveness or confusion that remains until people are treated
Almost always in people with diabetes
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Fingerstick glucose measurement
Immediate recovery following glucose infusion
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Transient ischemic attack or stroke
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Sudden fainting without warning
Fainting that may occur when people are upright or lying down
Sometimes loss of coordination or difficulty seeing, speaking, or swallowing
Usually in older people
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CT or MRI
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Less serious causes
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Increased pressure in the chest (for example, due to coughing or straining during urination or a bowel movement)
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Fainting during an activity that increases pressure in the chest
Warning symptoms (for example, dizziness, nausea, or sweating)
Recovery that is prompt but not immediate (within 5 to 15 minutes)
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Only a doctor's examination
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Strong emotion (such as pain, fear, or distress at the sight of blood)
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Fainting when experiencing strong emotion
Warning symptoms (for example, dizziness, nausea, or sweating)
Recovery that is prompt but not immediate (within 5 to 15 minutes)
A cause that is usually apparent
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Only a doctor's examination
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Migraine
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Fainting sometimes preceded by disturbances in sensation, vision, or other functions (called the aura)
Sensitivity to light
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Only a doctor's examination
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Standing for a long time
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A cause that is apparent based on the history
No other symptoms
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Only a doctor's examination
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Pregnancy
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In healthy women of childbearing age
No other symptoms
Usually in women with an early or unrecognized pregnancy
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Urine pregnancy test
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Hyperventilation
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Often tingling around the mouth or in the fingers before fainting
Usually during or in response to an emotional situation
Rapid breathing, which may not be noticed by the person or by others
Typically in younger people
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Only a doctor's examination
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Drugs such as most drugs used to lower the blood pressure (but rarely beta-blockers), antipsychotic drugs (mainly phenothiazines), loop diuretics, nitrates, quinidine, and tricyclic antidepressants
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Light-headedness, followed by fainting within several minutes of sitting up or standing
A drop in blood pressure when standing, detected during the examination
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A doctor's examination
Sometimes tilt table testing
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Malfunction of the autonomic nervous system (which regulates internal body processes that require no conscious effort, such as blood pressure)
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Light-headedness, followed by fainting within several minutes of sitting up or standing
A drop in blood pressure when standing, detected during the examination
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A doctor's examination
Sometimes tilt table testing
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Deconditioning caused by bed rest for many days
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Light-headedness, followed by fainting within several minutes of sitting up or standing
A drop in blood pressure when standing, detected during the examination
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A doctor's examination
Sometimes tilt table testing
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Anemia
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Light-headedness, followed by fainting within several minutes of sitting up or standing
Chronic fatigue
Sometimes dark stools or heavy menstrual periods
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A complete blood count
Stool tests to check for blood
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*Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present.
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†In all people who have fainted, ECG is done, and oxygen levels in the blood are measured with a sensor placed on a finger (pulse oximetry).
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CT = computed tomography; ECG = electrocardiography; MRI = magnetic resonance imaging.
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Testing:
Testing typically is done unless people have an obvious, harmless emotional trigger and otherwise feel well. Doctors choose tests based on the suspected cause.
In general, if fainting results in an injury or has happened several times (particularly within a brief period), more intensive evaluation is warranted.
People with suspected heart disorders, including heart attack, abnormal heart rhythm, or heart valve abnormality are usually admitted to the hospital for evaluation.
ECG is done. ECG may show a heart rhythm disturbance or other heart problem but sometimes is normal if the abnormal heart rhythm has resolved. Sometimes doctors admit the person to a hospital to monitor the heart's activity for 24 hours. Less often, doctors may have the person wear a small heart monitor while at home (called continuous ambulatory ECG—see Diagnosis of Heart and Blood Vessel Disorders: Continuous Ambulatory Electrocardiography).
Oxygen in the blood is measured. Pulse oximetry is done during or immediately after an episode to identify low levels of oxygen in the blood (which may indicate a blood clot). If the level of oxygen in the blood is low, doctors do computed tomography (CT) or a lung scan to check for a blood clot.
Laboratory tests are done if physical examination findings suggest they are needed. However, all women of childbearing age should have a pregnancy test.
Echocardiography may be done in people with exercise-induced fainting, heart murmurs, or fainting that occurs with sitting or standing.
Tilt table testing is sometimes done if people have fainting when they stand up. It is also used to evaluate fainting that is caused by exercise if echocardiography or exercise stress testing does not reveal a cause.
Stress testing (see Diagnosis of Heart and Blood Vessel Disorders: Stress Testing) is done when doctors suspect a heart rhythm disturbance brought on by exercise. It is often done for patients with exercise-induced symptoms.
Electrophysiologic testing (tests that record the electrical activity and electrical pathways of the heart by means of wires passed through blood vessels into the heart) is sometimes done if other testing does not identify a heart rhythm disturbance in a person with unexplained recurrent episodes of fainting.
Electroencephalography may be done when doctors suspect a seizure.
CT and magnetic resonance imaging of the head and brain may be done when doctors suspect a central nervous system disorder.
Treatment
Specific treatment depends on the cause. For example, people who have fainting caused by an abnormal heart rhythm may need to have a pacemaker and/or defibrillator implanted.
If people see someone faint, they should check whether the person is breathing. If the person is not breathing, bystanders should call for emergency medical assistance and begin cardiopulmonary resuscitation (CPR), including applying an automated external defibrillator (AED) if one is available. Once the person reaches the hospital, doctors will treat the cause of the fainting with drugs or appropriate measures, such as direct-current cardiac defibrillation to restart the heart or drugs or surgery to open blocked arteries.
A person who is breathing should remain lying down. If the person sits upright too rapidly, fainting may recur.
Essentials for Older People
Older people are particularly susceptible to fainting because blood flow to the brain decreases as people age. The most common cause of fainting in older people is inability of blood pressure to rapidly adjust when the person stands. Blood flow decreases because arteries become more rigid and less able to adjust rapidly, physical inactivity reduces the muscle activity that pushes blood through the veins and back to the heart, and heart disease decreases the effectiveness of blood pumping.
In older people, fainting often has more than one cause. For example, the combination of taking several drugs to treat heart disorders or high blood pressure and standing in a hot church during a long or emotional service may lead to fainting even though no single factor might be enough to cause fainting.
Key Points
Last full review/revision October 2012 by Lyall A. J. Higginson, MD
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