Can migraines cause Postural Orthostatic Tachycardia Syndrome (POT)?

Relationship Between Migraines and POTS

Migraines do not cause Postural Orthostatic Tachycardia Syndrome (POTS), but they frequently coexist due to shared underlying pathophysiological mechanisms involving autonomic nervous system dysfunction. 1

Understanding the Connection Between Migraines and POTS

Diagnostic Distinctions

When evaluating patients with orthostatic symptoms, it's important to distinguish between different conditions:

• POTS Definition: A clinical syndrome characterized by:

  • Frequent symptoms upon standing (lightheadedness, palpitations, tremulousness, weakness, blurred vision)
  • Heart rate increase ≥30 bpm during positional change from supine to standing (≥40 bpm in 12-19 year olds)
  • Absence of orthostatic hypotension (>20 mmHg reduction in systolic BP)
  • Standing heart rate often >120 bpm 1

• Migraine: Can be diagnosed by confirming that headache is provoked by movement rather than posture, establishing migrainous biology including history and trajectory of episodes, presence of aura, and vertigo 1

Epidemiological Relationship

• Migraine is the most common comorbidity in patients with POTS 2
• Both conditions predominantly affect young women 1
• POTS is frequently associated with other conditions including chronic fatigue syndrome, joint hypermobility syndrome, and headache 1

Shared Pathophysiological Mechanisms

Both conditions involve:

1. Autonomic Nervous System Dysfunction:

   • Migraine patients show interictal sympathetic hypofunction and ictal sympathetic hyperfunction 3
   • POTS involves dysregulation of the sympathetic nervous system 2

2. Vascular Dysregulation:

   • Both conditions involve alterations in central and peripheral hemodynamics 2

3. Central Sensitization:

   • Shared mechanism that increases vulnerability to both conditions 2

4. Stress Response Systems:

   • Activation of stress response systems during migraine episodes may exacerbate the pathology of POTS 3

Clinical Implications

Diagnostic Approach

When evaluating patients with orthostatic symptoms and headaches:

• Rule out Spontaneous Intracranial Hypotension (SIH): Consider SIH in patients with orthostatic headache that improves when lying flat 1

• Differentiate from other causes of orthostatic symptoms:

  • Orthostatic hypotension
  • Cervicogenic headache
  • Reflex syncope 1

• Standing test: Document objective evidence of postural tachycardia (increase in heart rate by >30 beats per minute) without orthostatic hypotension 1

Management Considerations

For patients with both migraine and POTS:

• Treatment approaches should consider the underlying pathophysiology of both conditions
• Non-pharmacologic and pharmacologic treatments that target shared mechanisms may provide significant benefit 2
• A multidisciplinary approach involving medication, education, and exercise has shown symptomatic improvement 4

Common Pitfalls to Avoid

1. Misattribution of causality: While migraines and POTS frequently coexist, one does not directly cause the other - they share underlying pathophysiological mechanisms 2, 3

2. Incomplete evaluation: Failing to perform formal standing tests to document objective evidence of postural tachycardia 1

3. Missing other comorbidities: Both conditions are associated with other syndromes including fibromyalgia, chronic fatigue syndrome, and joint hypermobility 4, 5

4. Overlooking autonomic testing: A negative standing test does not exclude POTS; additional autonomic testing should be considered if clinical suspicion is high 1

Understanding the relationship between these conditions is essential for proper diagnosis and management, as treatments targeting shared pathophysiological mechanisms may benefit both conditions simultaneously.