Diagnosis

Your doctor's goal in evaluating orthostatic hypotension is to find the underlying cause, and determine appropriate treatment for any health problems that may cause your low blood pressure. The cause isn't always known.

Your doctor may review your medical history, review your symptoms and conduct a physical examination to help diagnose your condition.

Your doctor also may recommend one or more of the following:

  • Blood pressure monitoring. Your doctor will measure your blood pressure both while you're sitting and while you're standing and will compare the measurements. Your doctor will diagnose orthostatic hypotension if you have a drop of 20 millimeters of mercury (mm Hg) in your systolic blood pressure or a drop of 10 mm Hg in your diastolic blood pressure within two to five minutes of standing up, or if standing causes signs and symptoms.
  • Blood tests. These can provide information about your overall health, including low blood sugar (hypoglycemia) or low red blood cell levels (anemia), both of which can cause low blood pressure.
  • Electrocardiogram (ECG or EKG). This noninvasive test detects irregularities in your heart rhythm or heart structure, and problems with the supply of blood and oxygen to your heart muscle.

    During this painless, noninvasive test, soft, sticky patches (electrodes) are attached to the skin of your chest, arms and legs. The patches detect your heart's electrical signals while a machine records them on graph paper or displays them on a screen.

    Sometimes, heart rhythm abnormalities come and go, and an ECG won't find any problems. If this happens, you may be asked to wear a 24-hour Holter monitor to record your heart's electrical activity as you go about your daily routine.

  • Echocardiogram. In this noninvasive exam, sound waves are used to produce a video image of your heart. Sound waves are directed at your heart from a wandlike device (transducer) that's held on your chest.

    The sound waves that bounce off your heart are reflected through your chest wall and processed electronically to provide video images of your heart in motion to detect underlying structural heart disease.

  • Stress test. A stress test is performed while you're exercising, such as walking on a treadmill. Or you may be given medication to make your heart work harder if you're unable to exercise. When your heart is working harder, your heart will be monitored with electrocardiography, echocardiography or other tests.
  • Tilt table test. A tilt table test evaluates how your body reacts to changes in position. You'll lie on a flat table that tilts to raise the upper part of your body, which simulates the movement from a horizontal to standing position. Your blood pressure is taken frequently as the table is tilted.
  • Valsalva maneuver. This noninvasive test checks the functioning of your autonomic nervous system by analyzing your heart rate and blood pressure after several cycles of a type of deep breathing: You breathe in deeply and push the air out through your lips, as if you were trying to blow up a stiff balloon.

Treatment

The goal of treatment for orthostatic hypotension is to restore normal blood pressure. That usually involves increasing blood volume, reducing the pooling of blood in your lower legs and helping blood vessels to push blood throughout your body.

Treatment often addresses the underlying cause — 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 should disappear.

When low blood pressure is caused by medications, treatment usually involves changing the dose of the medication or stopping it entirely.

Orthostatic hypotension treatments include:

  • Lifestyle changes. Your doctor may suggest several lifestyle changes, including drinking enough water; drinking little to no alcohol; avoiding overheating; elevating the head of your bed; avoiding crossing your legs when sitting; and standing up slowly.

    If you don't also have high blood pressure, your doctor might suggest increasing the amount of salt in your diet. If your blood pressure drops after eating, your doctor may recommend small, low-carbohydrate meals.

  • Compression stockings. Compression stockings and garments or abdominal binders may help reduce the pooling of blood in your legs and reduce the symptoms of orthostatic hypotension.
  • Medications. 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. Midodrine raises standing blood pressure levels by limiting expansion of your blood vessels, 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, others), are sometimes used, too, either alone or with other medications for people who aren't helped with lifestyle changes or other medications.

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this disease.

Lifestyle and home remedies

Some simple steps help manage or prevent orthostatic hypotension. Your doctor may give you several suggestions, including:

  • Increase salt in your diet. This must be done carefully and only after discussing it with your doctor. Too much salt can cause your blood pressure to increase beyond a healthy level, creating new health risks.
  • Eat small meals. If your blood pressure drops after eating, your doctor may recommend small, low-carbohydrate meals.
  • Ask about vitamin supplements. Both anemia and vitamin B-12 deficiency can affect blood flow and worsen symptoms of orthostatic hypotension, so iron and vitamin supplements might be helpful for you if you're deficient.
  • Get plenty of fluids. Keeping hydrated helps prevent symptoms of low blood pressure. Drink plenty of water before long periods of standing, or any activities that tend to trigger your symptoms.
  • Avoid alcohol. Alcohol can worsen orthostatic hypotension, so limit or avoid it completely.
  • Exercise. Regular cardiovascular and strengthening exercises may help reduce symptoms of orthostatic hypotension. Avoid exercising in very hot, humid weather. Stretch and flex your calf muscles before sitting up. If symptoms strike, squeeze your thigh, abdominal and buttock muscles. Squat, march in place or rise onto your tiptoes.
  • Avoid bending at the waist. If you drop something on the floor, squat with your knees to recover it.
  • Wear waist-high compression stockings. These may help improve blood flow and reduce the symptoms of orthostatic hypotension. Wear them during the day, but take them off for bed and anytime you lie down.
  • Get up slowly. You may be able to reduce the dizziness and lightheadedness that occur with orthostatic hypotension by moving slowly from a lying to standing position. Also, when getting out of bed, sit on the edge of your bed for a minute before standing.
  • Elevate your head in bed. Sleeping with the head of your bed slightly elevated can help fight the effects of gravity.
  • Move your legs while standing. If you begin to get symptoms while standing, cross your thighs in a scissors fashion and squeeze, or put one foot on a ledge or chair and lean as far forward as possible. These maneuvers encourage blood to flow from your legs to your heart.

Preparing for your appointment

No special preparations are necessary to have your blood pressure checked. But it's helpful if you wear a short-sleeved shirt or a loosefitting long-sleeved shirt that can be pushed up during your evaluation so that the blood pressure cuff can fit around your arm properly.

Take your blood pressure regularly at home, and keep a log of your readings. Bring the log with you to your doctor's appointment.

Take your blood pressure before and after each of the activities below. Lie down for the first reading. Complete the activity, then wait one minute. Stand and take the second reading.

  • First thing in the morning
  • After you eat
  • When your symptoms are least severe
  • When your symptoms are most severe
  • When you take your blood pressure medications
  • One hour after you take your blood pressure medications

Because appointments can be brief and because there's often a lot to discuss, it's a good idea to be prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

  • Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet for a blood test.
  • Write down any symptoms you're experiencing, including any that may seem unrelated to low blood pressure.
  • Write down key personal information, including a family history of low blood pressure and any major stresses or recent life changes.
  • Make a list or bring bottles of all medications, vitamins or supplements that you're taking because some medications — such as over-the-counter cold medicines, antidepressants, birth control pills and others — can affect your blood pressure. Don't stop taking any prescription medications that you think may affect your blood pressure without your doctor's advice.
  • Take a family member or friend along, if possible. Sometimes it can be difficult to remember all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
  • Be prepared to discuss your diet and exercise habits, especially the amount of salt in your diet. If you don't already follow a diet or exercise routine, be ready to talk to your doctor about any challenges you might face in getting started.
  • Write down questions to ask your doctor.

Your time with your doctor may be limited, so preparing a list of questions may help you make the most of your time together. List your questions from most important to least important in case time runs out. For low blood pressure, some basic questions to ask your doctor include:

  • What's the most likely cause of my symptoms?
  • Could my medications be a factor?
  • What are other possible causes for my symptoms or condition?
  • What kinds of tests will I need?
  • What's the most appropriate treatment?
  • What foods should I eat or avoid?
  • What's an appropriate level of physical activity?
  • Would losing weight help my condition?
  • Should I see a dietitian?
  • How often should I be screened for low blood pressure?
  • Should I learn to measure my own blood pressure at home?
  • What are the alternatives to the primary approach that you're suggesting?
  • I have other health conditions. How can I best manage these conditions together?
  • Are there any dietary or activity restrictions that I need to follow?
  • Should I see a specialist?
  • Is there a generic alternative to the medicine you're prescribing me?
  • Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask additional questions during your appointment.

What to expect from your doctor

Your doctor will probably ask you questions. If you're prepared, you'll have more time to go over any topics you want to discuss. Your doctor may ask:

  • When did you first begin experiencing symptoms?
  • Have your symptoms been continuous or occasional?
  • How severe are your symptoms?
  • What, if anything, seems to improve your symptoms?
  • What, if anything, appears to worsen your symptoms?
  • Do you have any known medical problems?
  • Are you currently taking medication?
  • Do you ever temporarily stop taking your medications because of side effects or because of the expense?
  • Have you lost or gained weight recently?
  • How is your appetite?
July 11, 2017
References
  1. Orthostatic hypotension. Merck Manual Professional Version. http://www.merckmanuals.com/professional/cardiovascular_disorders/symptoms_of_cardiovascular_disorders/orthostatic_hypotension.html?qt=orthostatic hypotension&alt=sh. Accessed March 23, 2017.
  2. What is hypotension? National Heart, Lung, and Blood Institute. http://www.nhlbi.nih.gov/health/health-topics/topics/hyp/. Accessed March 23, 2017.
  3. Kaufmann H, et al. Mechanisms, causes, and evaluation of orthostatic hypotension. http://www.uptodate.com/home. Accessed March 23, 2017.
  4. Low blood pressure. American Heart Association. http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/AboutHighBloodPressure/Low-Blood-Pressure_UCM_301785_Article.jsp. Accessed March 23, 2017.
  5. Shen WK, et al. 2017 ACC/AHA/HRS Guideline for the evaluation and management of patients with syncope. Heart Rhythm. In press. Accessed March 23, 2017.
  6. What is an electrocardiogram? National Heart, Lung, and Blood Institute. http://www.nhlbi.nih.gov/health/health-topics/topics/ekg/. Accessed March 23, 2017.
  7. What is echocardiography? National Heart, Lung, and Blood Institute. http://www.nhlbi.nih.gov/health/health-topics/topics/echo/. Accessed March 23, 2017.
  8. Kaufmann H, et al. Treatment of orthostatic and postprandial hypotension. http://www.uptodate.com/home. Accessed March 23, 2017.
  9. Gibbons CH, et al. The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypotension. Journal of Neurology. 2017 Jan 3.
  10. Drug approval package: Northera (droxidopa) capsules approval letter. U.S. Food and Drug Administration. http://www.accessdata.fda.gov/drugsatfda_docs/nda/2014/203202Orig1s000TOC.cfm. Accessed March 21, 2017.
  11. AskMayoExpert. Orthostatic hypotension initial evaluation. Rochester, Minn.: Mayo Foundation for Medical Education and Research; August 2016.
  12. AskMayoExpert. Orthostatic hypotension initial treatment. Rochester, Minn.: Mayo Foundation for Medical Education and Research; August 2016.
  13. Low PA (expert opinion). Mayo Clinic, Rochester, Minn. April 3, 2017.

Orthostatic hypotension (postural hypotension)