POTS is a condition that involves feeling faint or dizzy when you stand up and better when you lie down. Also known as postural orthostatic tachycardia syndrome, it is a disorder of the autonomic nervous system that affects an estimated one to three million Americans.
The most common symptoms include dizziness, heart palpitations, brain fog, fatigue, and nausea. They appear when upright and ease when lying down.
Here, we cover the full symptom list, four recognized subtypes, how POTS is identified, and how it is managed.
Key Insights About POTS
- POTS is a form of dysautonomia where the autonomic nervous system fails to regulate blood flow when you stand, causing the heart rate to spike abnormally.
- The most common symptoms are dizziness, heart palpitations, brain fog, fatigue, and nausea that appear when standing and ease when lying down.
- POTS can develop through multiple pathways, including nerve damage, low blood volume, hormonal overactivity, and chronic stress, and more than one can be present at the same time.
- It is confirmed when heart rate increases by 30 or more beats per minute within 10 minutes of standing, confirmed through a tilt table test or 10-minute standing test.
- A combination of dietary changes, progressive exercise, lifestyle adjustments, and targeted medication can meaningfully reduce symptoms for most patients.
What Is POTS (Postural Orthostatic Tachycardia Syndrome)?
Postural orthostatic tachycardia syndrome (POTS) is a condition where your heart rate spikes abnormally fast when you stand up.
It is a form of dysautonomia, meaning it stems from a malfunction in the autonomic nervous system, the system that controls involuntary functions like heart rate, blood pressure, and circulation.
POTS falls under the broader category of orthostatic intolerance, meaning the body fails to properly adjust blood flow when you change positions.
When a healthy person stands up, the autonomic nervous system responds automatically. Blood vessels tighten, heart rate adjusts slightly, and circulation stays balanced. The brain keeps receiving the blood flow it needs.
In POTS, that coordination breaks down. Blood vessels fail to constrict properly. Blood pools in the legs and abdomen. The brain gets less blood than it needs, and the heart races trying to make up the difference.
Clinically, POTS is confirmed when heart rate increases by at least 30 beats per minute within 10 minutes of standing in adults, or at least 40 beats per minute in adolescents, without a significant drop in blood pressure. [1]
Breaking down the name helps clarify what is actually happening:
- Postural – related to the position of your body
- Orthostatic – related to standing upright
- Tachycardia – a faster-than-normal heart rate
- Syndrome – a collection of symptoms that occur together
What makes POTS distinct from a simple fast heart rate is that the trigger is positional. Lying down, most patients feel fine. But after standing, symptoms begin.
How Common Is POTS?
POTS affects an estimated 1 to 3 million Americans [2]. Most of them are women between the ages of 15 and 50, though men and children can develop it too.
It often goes undiagnosed for months or even years. Patients frequently pass through multiple specialists before anyone connects the symptoms to an autonomic problem.
Awareness has grown significantly since 2020, partly because post-COVID illness has introduced POTS to a much broader patient population than before. [3]
Who Can Get POTS?
POTS most commonly develops in women between the ages of 15 and 50, but it is not exclusive to that group. Men, teenagers, and older adults can develop it too.
Certain experiences appear to trigger the onset of POTS in people who may already have an underlying vulnerability:
- Viral or serious infections: mononucleosis, COVID-19, and other significant infections are among the most common triggers
- Pregnancy: hormonal and circulatory changes can destabilize autonomic function
Surgery or physical trauma: including head injuries and procedures requiring prolonged bed rest- Autoimmune conditions: lupus, Sjogren’s syndrome, and celiac disease are frequently associated with POTS
- Joint hypermobility disorders: particularly Ehlers-Danlos syndrome, which shares a strong established link with POTS
- Mast cell activation disorders: research continues to uncover significant overlap between these conditions [4]
- Chronic stress and adrenal exhaustion: patients who develop POTS following prolonged emotional or physical stress represent a distinct group that is rarely identified in standard care
POTS can run in families. Researchers have not found one single gene that causes it, but genetics clearly play a role.
A 2024 genomic study identified multiple genes connected to POTS, including genes that influence how the autonomic nervous system functions and how the heart regulates its rate. [5]
The research is still catching up. What we do know is that some people seem to be wired from the start in a way that makes them more susceptible, especially when the right trigger comes along.
Is POTS a Serious Condition?
POTS is not life-threatening, but that does not mean it is minor. For many patients, it is genuinely disabling.
The impact of POTS on daily functioning is well documented. A large-scale study of 5,556 adults with physician-confirmed POTS found that over 70 percent of participants had lost income due to POTS symptoms.
More than a third lost over $10,000 in a single year. Nearly all reported out-of-pocket medical expenses since diagnosis, with more than half spending $10,000 or more.
For many patients, the condition does not just affect health; it reshapes their entire financial reality.
What Happens to Your Body When You Have POTS
To understand POTS, it helps to first understand what a healthy body does the moment you stand up.
When you go from lying down to standing, gravity immediately pulls blood toward your legs and abdomen.
Your autonomic nervous system responds within seconds. It signals your blood vessels to tighten and releases hormones, primarily norepinephrine and epinephrine, to nudge your heart rate up slightly. Blood gets pushed back up toward your heart and brain.
The whole process happens automatically, and most people never notice it. In POTS, that process breaks down.
The blood vessels do not respond efficiently to the signal to constrict. Blood continues pooling in the lower half of the body instead of returning upward.
The brain receives less blood than it needs, and the nervous system keeps releasing more norepinephrine and epinephrine, trying to correct the problem.
Because the heart can still respond to those hormones even when the blood vessels cannot, the heart rate climbs rapidly.
That compensatory spike is what defines POTS clinically, and it is also what causes most of the symptoms patients feel.
It is worth noting that the heart itself is structurally normal in most POTS patients. The problem is not the heart. The problem is the system that manages circulation when you change positions.
Some research identified the core issue as blunted arterial vasoconstriction, meaning the arteries simply fail to tighten the way they should, causing blood to redistribute passively into the lower body rather than being actively pushed back up. [6]
Three things tend to drive POTS symptoms:
- Reduced circulating blood volume: Many POTS patients have a measurably lower total blood volume than healthy individuals, making the system even more vulnerable to positional changes. [7]
- Blood pooling below the heart: The longer a person stays upright, the more blood accumulates in the legs and abdomen, sometimes causing visible discoloration of the lower limbs.
- Elevated stress hormones: As norepinephrine and epinephrine continue building in the bloodstream, trying to compensate, they produce their own cascade of effects: a pounding heart, shakiness, chest discomfort, and a state of internal alarm that many patients mistake for anxiety.
What Are the Symptoms of POTS?
POTS symptoms are positional. They show up when you stand and ease when you lie down. Beyond that, they vary widely from person to person.
Symptoms typically include some of these:
Dizziness or lightheadedness: Most noticeable when standing up or during prolonged standing- Fainting or near-fainting: Affects roughly 30 percent of POTS patients
- Heart palpitations or racing heart: A pounding, fluttering, or skipping sensation in the chest
- Fatigue: Not ordinary tiredness; a heaviness that rest does not fix
- Brain fog: Difficulty thinking clearly, concentrating, or remembering
- Shortness of breath: Feeling breathless with minimal exertion or simply from standing
- Chest pain: Can accompany palpitations or occur on its own
- Headaches: Often worse when upright, slightly better when lying down
- Nausea: Sometimes accompanied by vomiting during a flare
- Bloating and digestive discomfort: The gut is directly regulated by the autonomic nervous system
- Shakiness or tremors: Particularly noticeable in the hands
- Excessive sweating: Can happen without heat or physical effort
- Anxiety or inner nervousness: Caused by elevated stress hormones, not a psychological disorder
- Pale face, purple or reddish hands and feet: Occurs when blood pools in the lower limbs while upright
- Sleep disruption: Racing heart, chest discomfort, and sweating can interrupt sleep even at rest
- Exercise intolerance: Symptoms worsen during or after activity, sometimes lasting hours or days
One thing worth knowing: even though anxiety and a racing heart are on this list, POTS is not a psychological condition.
The nervous system is flooding the body with norepinephrine and epinephrine, which creates sensations that feel emotional but are entirely physical in origin.
What Triggers POTS Symptoms to Get Worse
Symptoms are not always consistent. Certain situations push the autonomic system closer to its limit, and recognizing them early makes a real difference:
- Heat: Hot showers, warm weather, and heated rooms worsen blood pooling
- Prolonged standing: Waiting in line, shopping, standing at a counter
- Dehydration or skipping meals: Lower blood volume makes everything harder
- Physical exertion: Even mild activity can trigger or extend a flare
- Illness: A cold or infection can disrupt an already fragile autonomic balance
- Menstruation: Hormonal shifts worsen symptoms for many women
- Alcohol: Dilates blood vessels and increases fluid loss simultaneously
- Stress: Activates the same hormonal cascade that drives POTS symptoms
What Causes POTS? Understanding How It Develops
Researchers have not pinned down a single cause. Instead, they’ve found that POTS develops through several different pathways, and more than one can be present in the same person at the same time.
There is also growing evidence that autoimmune activity plays a role in some cases, where the immune system produces antibodies that interfere with autonomic nervous system receptors. [8]
This may help explain why POTS so often follows a viral illness or infection.
There are four recognized pathways that cause different types of POTS. These are:
Neuropathic POTS
This happens when small fiber nerves in the legs and abdomen are damaged. These nerves are responsible for signaling blood vessels to constrict when you stand.
When they are not working properly, blood vessels stay relaxed, blood pools downward, and the heart races trying to compensate.
Hyperadrenergic POTS
This type involves an overactive sympathetic nervous system that produces abnormally high levels of norepinephrine when upright. Instead of a measured hormonal response, the body floods the system.
The result is a racing heart, elevated blood pressure, tremors, and an intense inner nervousness that is frequently mistaken for anxiety.
This pathway can be connected to chronic stress and adrenal dysfunction.
When the body has been running on high alert for an extended period, the sympathetic nervous system can become chronically overactivated, setting the stage for hyperadrenergic POTS to develop or worsen.
Hypovolemic POTS
Some people with POTS simply do not have enough circulating blood volume. Even without nerve damage or hormonal overactivity, a lower-than-normal blood volume means less blood reaches the heart and brain when standing.
The body compensates the only way it can, by raising the heart rate.
Secondary POTS
Sometimes, POTS is not the primary condition. It develops as a consequence of something else, an underlying illness that has disrupted autonomic function along the way. Conditions associated with secondary POTS include:
- Diabetes
- Lyme disease
- Lupus
- Sjogren’s syndrome
- Other autoimmune disorders
Why Does Stress Make POTS Worse?
This is one of the most important questions POTS patients rarely get answered at a doctor’s appointment.
The short answer is that stress and POTS run on the same hormonal system. When one gets worse, it pulls the other along with it.
The Body’s Stress Response and POTS
Your body does not manage stress through a single organ or system. It manages it through an interconnected network of organs and circuits working together, known as the NeuroEndoMetabolic (NEM) Stress Response.
When stress hits, the entire network activates together, not just one gland or hormone in isolation.
At the center of this response is the hypothalamic-pituitary-adrenal (HPA) axis. The hypothalamus signals the adrenal glands to release cortisol and norepinephrine. For short-term stress, this works exactly as intended.
The problem starts when stress never fully stops.
Chronic stress keeps the adrenal glands in a constant state of activation. Norepinephrine accumulates. The sympathetic nervous system stays switched on.
This is called sympathetic overtone, and it is the hormonal environment where POTS becomes a problem.
The Cardionomic Circuit: Where POTS and Stress Collide
Within the NEM framework, the circuit most directly connected to POTS is the Cardionomic Circuit, which includes the autonomic nervous system, the heart, and the adrenal glands.
When chronic stress pushes this circuit into overdrive, the adrenal glands keep releasing norepinephrine and epinephrine to maintain the fight-or-flight state. The heart rate climbs. Blood pressure becomes unpredictable.
In the early stages, this produces subclinical POTS-like symptoms. Left unaddressed, it can progress into clinical POTS.
Norepinephrine Overload: What It Actually Feels Like
Too much norepinephrine in the brain keeps it locked in high-alert mode. Falling asleep becomes difficult. You wake up after a few hours and cannot get back to sleep.
During the day, there is a persistent sense of nervousness that has nothing to do with your actual circumstances.
It also travels to the heart. A pounding heartbeat, even at rest, is often norepinephrine at work.
Over time, sustained norepinephrine overload can directly trigger or worsen hyperadrenergic POTS.
Epinephrine: The Escalation Most Doctors Miss
When norepinephrine stays elevated long enough, the body begins converting part of it into epinephrine.
Epinephrine is stronger. It is the hormone of last resort, released when the body believes it is in genuine danger. Once it is in the bloodstream, nothing counters it directly.
In severe or prolonged stress, the adrenal medulla releases epinephrine directly into circulation. The heart accelerates. Blood pressure spikes. The whole cardiovascular system is pushed harder.
This is called a reactive sympathetic response, and it produces symptoms that look exactly like a POTS flare because physiologically, that is what it is.
What This Means for POTS Patients
If your POTS developed after a period of burnout, prolonged illness, emotional loss, or relentless overwork, your stress response system is likely part of the picture.
Standard POTS care addresses the cardiovascular symptoms. It does not address the hormonal environment that produces them.
That distinction matters. Managing salt intake and heart rate helps day to day. But for patients with an adrenal component driving their POTS, recovery that lasts requires addressing the root, not just the result.
Is POTS Just Anxiety? Why POTS Is So Often Misdiagnosed
POTS is not anxiety. The symptoms overlap, but the cause is completely different.
A racing heart, dizziness, shakiness, and chest tightness look like anxiety on paper. What is actually happening is the body flooding itself with norepinephrine and epinephrine, trying to fix a circulation problem.
The sensations feel emotional. The root cause is physical.
The misdiagnosis rate reflects how often this gets missed. A survey of 4,835 POTS patients found that the typical wait for a correct diagnosis was around two years. For many, it stretched to six. [9]
Research confirms the pattern. POTS is frequently mistaken for an anxiety disorder because of its hyperadrenergic symptoms, not because patients have a psychiatric condition. [10]
Standard cardiac tests come back normal because the heart itself is structurally fine. Without positional testing, the dysfunction never shows up, and patients leave with a psychiatric referral instead of a diagnosis.
Conditions That Look Like POTS and How to Tell Them Apart
Several conditions share symptoms with POTS, which is a major reason why diagnosis takes so long.
The table below outlines the most commonly confused conditions and what sets each one apart from POTS:
| Condition | Shared Symptoms With POTS | Key Difference |
| Anxiety and Panic Disorder | Racing heart, breathlessness, dizziness, shakiness | Anxiety is triggered by psychological stress. POTS symptoms are triggered by standing, regardless of emotional state. |
| Orthostatic Hypotension | Dizziness and lightheadedness on standing | Involves a significant blood pressure drop of 20+ mmHg systolic within 3 minutes of standing. POTS involves heart rate increase without that early blood pressure drop. |
| Inappropriate Sinus Tachycardia (IST) | Persistent fast heart rate, palpitations, fatigue | IST involves a consistently elevated resting heart rate above 100 bpm in all positions. POTS heart rate elevation is specifically triggered by standing. |
| Vasovagal Syncope | Fainting, dizziness, nausea, pale skin | Involves a sudden drop in both heart rate and blood pressure, often triggered by pain or emotional stress. POTS involves sustained heart rate elevation without the same vagal drop. |
| Chronic Fatigue Syndrome / ME-CFS | Profound fatigue, brain fog, exercise intolerance | ME-CFS does not require a positional heart rate increase for diagnosis. The two conditions frequently co-exist. |
| Mast Cell Activation Syndrome (MCAS) | Flushing, rapid heart rate, dizziness, GI symptoms, brain fog | MCAS involves inappropriate mast cell reactions with identifiable triggers. POTS and MCAS frequently co-exist, particularly in Ehlers-Danlos patients. |
| Ehlers-Danlos Syndrome (EDS) | Fatigue, dizziness, autonomic symptoms, joint hypermobility | EDS is a connective tissue disorder. It can contribute to POTS through vascular laxity and blood pooling, but EDS itself is not POTS. |
| Adrenal Insufficiency or Adrenal Fatigue | Fatigue, dizziness on standing, low blood pressure, salt craving | Adrenal insufficiency involves measurably low cortisol. Adrenal fatigue involves a functional decline that standard tests often miss, and both can drive POTS-like symptoms. |
How Is POTS Identified?
POTS can be difficult to identify because its symptoms affect so many organ systems. Most patients have been symptomatic for months or years before the right test is ordered.
Your doctor will start with a physical exam, review your symptoms and medical history, and then arrange one or more positional tests to confirm their suspicions.
Medical History and Symptom Review
Your doctor will ask about when symptoms started, what triggers them, and how they change with position.
A clear pattern of symptoms worsening on standing and improving when lying down is a strong clinical signal before any test is run.
The 10-Minute Standing Test
For this test, you lie down, then stand upright while heart rate and blood pressure are measured over 10 minutes.
A heart rate increase of 30 or more beats per minute in adults, or 40 in adolescents, meets the diagnostic threshold.
The Tilt Table Test
In this test, you are secured to a flat table, then mechanically raised to an upright position. Heart rate and blood pressure are monitored continuously throughout.
You likely have POTS if all three apply:
- Heart rate increases abnormally when upright.
- Symptoms worsen in the upright position.
- No orthostatic hypotension develops in the first three minutes.
Results can sometimes be borderline or inconclusive, particularly if testing occurs on a lower-symptom day.
Active Stand Test
This test is a simpler alternative that can be performed in a standard clinic. The patient moves from lying to standing while continuous heart rate monitoring captures their immediate response.
Additional Diagnostic Tests
- QSART: Measures autonomic nerve function controlling sweating.
- Autonomic breathing test: Assesses heart rate and blood pressure response to controlled breathing.
- Valsalva maneuver: Tests autonomic nerves regulating the cardiovascular system.
- Skin nerve biopsy: Checks for small fiber nerve damage in suspected neuropathic POTS.
- Blood and urine tests: Rule out other causes and check norepinephrine levels in hyperadrenergic POTS.
How Is POTS Managed?
There is no cure for POTS. But for most people, symptoms can be meaningfully reduced with the right combination of diet, movement, medication, and lifestyle adjustments.
These are the approaches that make the most difference:
Diet and Nutrition for POTS
Start with salt and fluids. This is the foundation of POTS management.
However, this advice is specifically for low blood pressure-related POTS. If you have high blood pressure or other conditions, adding salt to your diet may worsen the situation. Be sure to talk to your doctor first.
- Sodium: 3,000 to 10,000 mg per day. Good sodium sources include broth, olives, pickles, and nuts. Avoid relying on chips and crackers. Again, avoid this if you have high blood pressure.
- Fluids: 2 to 2.5 liters of water daily
- Meals: Smaller and more frequent. Large meals redirect blood to digestion and trigger symptoms.
Exercise and Physical Activity for POTS
Exercise builds blood volume and retrains the autonomic nervous system over time. Start reclined and progress slowly.
- Isometric exercises: Contract large muscle groups while lying down, before getting up each morning.
- Transition slowly: Lying to sitting to standing, with pauses at each stage.
- Walking program: Start at your symptom-free baseline and add gradually.
- Reclined aerobics: Rowing, recumbent cycling, and swimming are most effective.
- Gentle yoga: Focus on breathing and slow transitions.
Lifestyle Changes That Help Manage POTS Symptoms
- Raise the head of your bed six to ten inches to reduce overnight fluid shifts.
- Wear compression garments to reduce blood pooling in the legs.
- Monitor blood pressure and heart rate daily at consistent times.
- Keep cool. Heat worsens pooling; plan around it.
- Move rather than stand still. Crossing legs, tensing muscles, and shifting weight all help push blood upward.
Medications Used to Manage POTS
No medication is FDA-approved specifically for POTS. Most are recommended off-label.
| Medication | How It Helps |
| Fludrocortisone | Increases sodium retention and blood volume |
| Midodrine | Constricts blood vessels, raises standing blood pressure |
| Beta blockers | Reduce heart rate and adrenal hormone effects on the heart |
| Pyridostigmine | Improves nerve signaling to blood vessels |
| Clonidine | Reduces sympathetic nervous system overactivity |
When Should You See a Doctor About POTS Symptoms?
If your symptoms consistently worsen when standing and improve when lying down, that pattern alone is worth bringing to a doctor. Do not wait until things become unmanageable.
See a doctor if you are experiencing:
- Fainting or frequent near-fainting episodes
- A heart rate that spikes significantly every time you stand
- Fatigue that does not improve with rest
- Symptoms that are affecting your ability to work, study, or function daily
If you have already seen multiple doctors without answers, the issue may not be your symptoms. It may be that the underlying autonomic and adrenal connections have not been evaluated.
Lam Clinic specializes in exactly this. Using functional labs, systems-based diagnostics, and personalized care plans, our team works with patients whose conditions others have struggled to identify and address.
Conclusion
POTS symptoms are positional, systemic, and frequently misdiagnosed. They appear when you stand, ease when you lie down, and affect everything from your heart rate to your digestion to your ability to think clearly.
The condition develops through multiple pathways, requires specific positional testing to confirm, and responds best to a combination of diet, movement, medication, and care that addresses the underlying drivers.
If you have been living with these symptoms without clear answers, a more thorough evaluation is the next step. Lam Clinic is built for exactly that kind of situation.
Contact Lam Clinic today to schedule a consultation and find out what a complete, personalized evaluation looks like for your specific case.