In some people, particularly older people, blood pressure drops excessively when they sit or stand up (orthostatic or postural hypotension). Symptoms of faintness, light-headedness, dizziness, confusion, or blurred vision occur within seconds to a few minutes of standing (particularly after lying in bed or sitting for a long time) and resolve rapidly when the person lies down. However, some people fall, faint, or very rarely have a brief seizure. Symptoms are often more common and worse after people exercise or have consumed alcohol and/or a heavy meal.

Some younger people experience similar symptoms upon standing but without having a drop in blood pressure. Often, their heart rate increases (tachycardia) more than normal upon standing, so this condition is called postural orthostatic tachycardia syndrome (POTS). The reason why such people feel dizzy despite having normal blood pressure is not yet clear.

Causes

Dizziness or light-headedness when standing up occurs as a result of abnormal blood pressure regulation. Normally, when people stand, gravity causes blood to pool in the veins of the legs and trunk. This pooling lowers the blood pressure and the amount of blood the heart pumps to the brain. Low blood flow to the brain causes the dizziness and other symptoms. To compensate, the nervous system quickly increases the heart rate and constricts blood vessels, which rapidly returns blood pressure to normal before symptoms can develop. The part of the nervous system responsible for this compensation is the autonomic nervous system (see Autonomic Nervous System Disorders: Overview of the Autonomic Nervous System).

Many disorders can cause problems with blood pressure regulation and lead to dizziness when standing up. Categories of causes include

• Malfunction of the autonomic nervous system due to disorders or drugs
• Decreased ability of the heart to pump blood
• Decreased blood volume (hypovolemia)
• Faulty hormonal responses

Causes differ depending on whether symptoms are new or have been present for some time.

Common causes: The most common causes of new dizziness when standing up include

• Decreased blood volume (as may result from dehydration or blood loss)
• Drugs
• Prolonged bed rest
• An underactive adrenal gland (adrenal insufficiency)

The most common causes of dizziness when standing up that has been present for a long time (chronic) include

• Age-related changes in blood pressure regulation
• Drugs
• Malfunction of the autonomic nervous system

Evaluation

People who become dizzy or light-headed when standing up often recover quickly when they sit down and then slowly stand again. However, it is usually important to determine what is causing the dizziness. The following information can help people decide when to see a doctor and help them know what to expect during the evaluation.

Warning signs: In people who become dizzy or light-headed when standing up, certain symptoms and characteristics are cause for concern. They include

• Blood in the stool or black, tarry stool
• Nervous system symptoms such as difficulty walking and/or poor coordination or balance

When to see a doctor: People who have warning signs and those who have fallen or fainted should see a doctor right away. Other people who have frequent or ongoing episodes of dizziness upon standing should see a doctor when practical. Typically a delay of a week or so is not harmful. People who have only an occasional episode of dizziness upon standing should call their doctor. The doctor will decide whether and how quickly to see the person depending on the other symptoms and medical history.

What the doctor does: The doctor first asks questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the dizziness and the tests that may need to be done.

Doctors ask

• How long the dizziness has been occurring
• Whether the person has fainted or fallen during an episode of dizziness
• Whether the person has experienced conditions that are known to cause dizziness (such as bed rest or fluid loss)
• Whether the person has a disorder (such as diabetes, Parkinson disease, or a cancer) that may cause dizziness
• Whether the person is taking a drug (for example, an antihypertensive) that may cause dizziness

The doctor then does a physical examination. The person lies down for 5 minutes, and then the doctor measures the blood pressure and heart rate. Blood pressure and heart rate are measured again after the person stands or sits up for 1 minute and again after standing or sitting for 3 minutes. The doctor may do a digital rectal examination to see whether the person might have some bleeding in the digestive tract. A neurologic examination to test strength, sensation, reflexes, balance, and gait is important.

The most common causes of sudden dizziness, drugs, bed rest, and decreased blood volume, are usually obvious. In people with long-term symptoms, findings such as movement problems may indicate Parkinson disease. Numbness, tingling, or weakness may indicate a nervous system disorder.

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Some Causes and Features of Dizziness or Light-Headedness When Standing Up Cause Common Features* Tests Central nervous system† disorders Multiple system atrophy (previously called Shy-Drager syndrome) Muscle stiffness Slow, shaky movements Loss of coordination and/or balance Incontinence or inability to urinate A doctor's examination Sometimes MRI Parkinson disease Muscle stiffness Tremor Slow, shaky movements and a shuffling gait Difficulty walking Only a doctor's examination Strokes if several have occurred In people who are known to have had strokes Only a doctor's examination Spinal cord disorders Syphilis that affects the spinal cord (tabes dorsalis) Intense, stabbing pains in the legs that come and go Unsteady walking Decreased sensation in the legs and numbness or tingling Blood tests and sometimes a spinal tap (to obtain cerebrospinal fluid) to check for syphilis Tumors Back pain Muscle weakness and decreased sensation in the legs MRI Peripheral nerve† disorders Amyloidosis Numbness, tingling, and weakness Biopsy Nerve damage caused by diabetes, excessive alcohol use, or nutritional deficiencies Often burning pain and/or numbness in the feet and hands Sometimes weakness Usually in people who are known to have a disorder that can cause nerve damage Nerve conduction testing and electromyography Pure autonomic failure (formerly called idiopathic orthostatic hypotension) Sometimes decreased sweating and intolerance of heat Constipation or loss of control over bowel movements (fecal incontinence) Difficulty emptying the bladder A doctor's examination Blood tests A decreased volume of blood (hypovolemia) Dehydration Thirst, decreased urination, and confusion Only a doctor's examination Excessive loss of blood Usually in people who have had an injury or surgery Blood in stool or black, tarry stool A doctor's examination, including testing stool for blood A complete blood count An underactive adrenal gland Weakness and fatigue Blood tests Heart and blood vessel disorders Chronic venous insufficiency (causing blood to pool in the legs) Long-lasting, nonpitting swelling in one or both legs Chronic mild discomfort or aching in the ankles or legs but no pain Sometimes reddish brown, leathery areas on the skin and shallow sores, usually on the lower legs Often varicose veins A doctor's examination Heart failure Shortness of breath and fatigue A doctor's examination Sometimes echocardiography (ultrasonography of the heart) Heart attack (myocardial infarction) Chest pain or pressure Shortness of breath or fatigue Sometimes in people who are known to have had a recent heart attack ECG and blood tests to measure substances that indicate heart damage (cardiac markers) High levels of the hormone aldosterone (hyperaldosteronism, usually caused by a tumor in the adrenal gland) Weakness, tingling, and muscle spasms Blood tests Drugs Drugs for high blood pressure or angina: Calcium channel blockers, clonidine, diuretics (such as furosemide), methyldopa, nitrates, prazosin, or rarely beta-blockers In people known to use of one of these drugs A doctor's examination Sometimes stopping the drug to see if symptoms go away Drugs that affect the central nervous system: Antipsychotics (particularly phenothiazines), monoamine oxidase inhibitors, or tricyclic or tetracyclic antidepressants In people known to use of one of these drugs Only a doctor's examination Sedatives: Alcohol or barbiturates In people known to use of one of these drugs Only a doctor's examination Other drugs: Quinidine or vincristine In people known to use of one of these drugs Only a doctor's examination Other problems Age-related changes in blood pressure regulation In older people No other symptoms Only a doctor's examination Bed rest if prolonged In people who have been at bed rest for a long time Only a doctor's examination A low level of potassium in the blood Muscle weakness and cramping Pins-and-needles sensation Blood tests *Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present. †The central nervous system includes the brain and spinal cord. The peripheral nervous system includes the nerves outside the brain and spinal cord. CT = computed tomography; ECG = electrocardiography; MRI = magnetic resonance imaging. Some Causes and Features of Dizziness or Light-Headedness When Standing Up Cause Common Features* Tests Central nervous system† disorders Multiple system atrophy (previously called Shy-Drager syndrome) Muscle stiffness Slow, shaky movements Loss of coordination and/or balance Incontinence or inability to urinate A doctor's examination Sometimes MRI Parkinson disease Muscle stiffness Tremor Slow, shaky movements and a shuffling gait Difficulty walking Only a doctor's examination Strokes if several have occurred In people who are known to have had strokes Only a doctor's examination Spinal cord disorders Syphilis that affects the spinal cord (tabes dorsalis) Intense, stabbing pains in the legs that come and go Unsteady walking Decreased sensation in the legs and numbness or tingling Blood tests and sometimes a spinal tap (to obtain cerebrospinal fluid) to check for syphilis Tumors Back pain Muscle weakness and decreased sensation in the legs MRI Peripheral nerve† disorders Amyloidosis Numbness, tingling, and weakness Biopsy Nerve damage caused by diabetes, excessive alcohol use, or nutritional deficiencies Often burning pain and/or numbness in the feet and hands Sometimes weakness Usually in people who are known to have a disorder that can cause nerve damage Nerve conduction testing and electromyography Pure autonomic failure (formerly called idiopathic orthostatic hypotension) Sometimes decreased sweating and intolerance of heat Constipation or loss of control over bowel movements (fecal incontinence) Difficulty emptying the bladder A doctor's examination Blood tests A decreased volume of blood (hypovolemia) Dehydration Thirst, decreased urination, and confusion Only a doctor's examination Excessive loss of blood Usually in people who have had an injury or surgery Blood in stool or black, tarry stool A doctor's examination, including testing stool for blood A complete blood count An underactive adrenal gland Weakness and fatigue Blood tests Heart and blood vessel disorders Chronic venous insufficiency (causing blood to pool in the legs) Long-lasting, nonpitting swelling in one or both legs Chronic mild discomfort or aching in the ankles or legs but no pain Sometimes reddish brown, leathery areas on the skin and shallow sores, usually on the lower legs Often varicose veins A doctor's examination Heart failure Shortness of breath and fatigue A doctor's examination Sometimes echocardiography (ultrasonography of the heart) Heart attack (myocardial infarction) Chest pain or pressure Shortness of breath or fatigue Sometimes in people who are known to have had a recent heart attack ECG and blood tests to measure substances that indicate heart damage (cardiac markers) High levels of the hormone aldosterone (hyperaldosteronism, usually caused by a tumor in the adrenal gland) Weakness, tingling, and muscle spasms Blood tests Drugs Drugs for high blood pressure or angina: Calcium channel blockers, clonidine, diuretics (such as furosemide), methyldopa, nitrates, prazosin, or rarely beta-blockers In people known to use of one of these drugs A doctor's examination Sometimes stopping the drug to see if symptoms go away Drugs that affect the central nervous system: Antipsychotics (particularly phenothiazines), monoamine oxidase inhibitors, or tricyclic or tetracyclic antidepressants In people known to use of one of these drugs Only a doctor's examination Sedatives: Alcohol or barbiturates In people known to use of one of these drugs Only a doctor's examination Other drugs: Quinidine or vincristine In people known to use of one of these drugs Only a doctor's examination Other problems Age-related changes in blood pressure regulation In older people No other symptoms Only a doctor's examination Bed rest if prolonged In people who have been at bed rest for a long time Only a doctor's examination A low level of potassium in the blood Muscle weakness and cramping Pins-and-needles sensation Blood tests *Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present. †The central nervous system includes the brain and spinal cord. The peripheral nervous system includes the nerves outside the brain and spinal cord. CT = computed tomography; ECG = electrocardiography; MRI = magnetic resonance imaging.

Testing: Unless the cause is obvious (for example, bed rest), testing is usually needed. The doctor usually does electrocardiography (ECG), a complete blood count, and other blood tests (for example, measuring levels of electrolytes). Other tests are done based on what doctors find during the examination, especially if the person's symptoms suggest a heart or nerve problem.

If doctors suspect a drug is causing the dizziness, they may ask the person to stop taking the drug and observe whether the dizziness also stops, thus confirming the cause.

Tilt table testing may be done when doctors suspect malfunction of the autonomic nervous system. The person lies flat on a special motorized table for several minutes. Then the table is tilted up at a 60˚ to 80° angle for 15 to 20 minutes while blood pressure and heart rate are continuously monitored. If blood pressure does not decrease, the person is given isoproterenol (a drug that stimulates the heart) intravenously in a dose large enough to accelerate the heart rate by 20 beats per minute, and the test is repeated. This procedure takes 30 to 60 minutes and is very safe.

Treatment

Any causes are treated when possible, including changing or stopping any causative drugs. However, many causes cannot be cured, and people must take measures to decrease their symptoms. Measures include lifestyle changes and drugs.

People requiring prolonged bed rest should sit up each day and exercise in bed when possible. People who are lying down or sitting should rise slowly and carefully. In general, it is helpful to consume adequate fluids, limit or avoid alcohol, and exercise regularly when feasible. Regular exercise of modest intensity increases the muscle tone in blood vessel walls, which reduces pooling of blood in the legs. Sleeping with the head of the bed raised may help relieve symptoms. For some people, increasing salt intake may increase water retention and lessen symptoms. Doctors may recommend that people increase their salt intake by liberally salting food or taking sodium chloride tablets. However, increasing salt intake may not be recommended for people with heart disorders.

Doctors may give fludrocortisone, a drug that helps the body retain salt and water and thus prevent blood pressure from dropping when a person stands. However, this drug may cause high blood pressure when people are lying down, heart failure, and low levels of potassium in the blood. Sometimes doctors combine propranolol or another beta-blocker with fludrocortisone. Midodrine is a drug that narrows both arteries and veins, helping prevent blood pooling. Side effects include tingling or numbness and itching. This drug is not recommended for people with coronary artery or peripheral arterial disease.

Other drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs) and L-dihydroxyphenylserine may help in some cases.

Essentials for Older People

Dizziness or light-headedness when standing occurs in about 20% of older people. It is more common among people with coexisting disorders, especially high blood pressure, and among residents of long-term care facilities. Many falls may result from dizziness when standing. Older people should avoid prolonged standing.

The increased incidence in older people is due to decreases in the responsiveness of the receptors that manage blood pressure plus increases in arterial wall stiffness that make it more difficult for arteries to move more blood to increase blood pressure. Decreases in receptor responsiveness delay the normal heart and blood vessel responses to standing. Paradoxically, high blood pressure, which is more common among older people, may contribute to poor receptor sensitivity, increasing vulnerability to dizziness when standing.

Key Points

• Dizziness or light-headedness when standing typically involves a decrease in body fluid volume or autonomic nervous system dysfunction.
• Aging often causes some degree of autonomic nervous system dysfunction, but doctors examine all affected people to ensure that no nervous system disorders are present.
• Tilt table testing is a common test of autonomic function.
• Treatment involves physical measures to reduce venous pooling, regular exercise, increased salt intake, and sometimes fludrocortisone or midodrine.

Last full review/revision October 2012 by Lyall A. J. Higginson, MD