What should I do if I experience dizziness after standing from a supine position?

Dizziness After Standing from Supine

You need to immediately measure orthostatic vital signs—blood pressure and heart rate after 5 minutes supine, then at 1 and 3 minutes after standing—to determine if you have orthostatic hypotension, which is the most likely cause of your symptoms and requires specific treatment. 1, 2

Immediate Assessment

Measure your orthostatic vital signs properly:

• Rest supine for 5 minutes, then measure blood pressure and heart rate 1, 2
• Stand up and measure again at 1 minute and 3 minutes 1, 2
• Keep your arm at heart level during all measurements 1

Orthostatic hypotension is diagnosed if you have:

• Systolic blood pressure drop ≥20 mmHg, OR 1, 2
• Diastolic blood pressure drop ≥10 mmHg, OR 1, 2
• Systolic blood pressure falls to <90 mmHg within 3 minutes of standing 1
• If you have supine hypertension, use a threshold of ≥30 mmHg systolic drop 2

Critical Distinction: Check Your Heart Rate Response

The heart rate response tells you the cause:

• Neurogenic orthostatic hypotension: Heart rate increases <15 bpm when standing—indicates autonomic nervous system dysfunction requiring specialized treatment 2, 3
• Non-neurogenic orthostatic hypotension: Heart rate increases appropriately (≥15 bpm)—suggests medications, dehydration, blood loss, or cardiac dysfunction 2

Other Patterns to Recognize

Initial orthostatic hypotension occurs within 15 seconds of standing with rapid recovery, causing brief lightheadedness 4, 2

Delayed orthostatic hypotension develops >3 minutes after standing with gradual blood pressure decline 4, 2

Postural Orthostatic Tachycardia Syndrome (POTS) causes severe symptoms with heart rate increase >30 bpm (or >120 bpm) within 10 minutes without blood pressure drop 1

Rule Out Benign Paroxysmal Positional Vertigo (BPPV)

BPPV causes brief spinning vertigo (not lightheadedness) lasting seconds to minutes with specific head movements, not just standing up. 4 If you experience true spinning vertigo rather than lightheadedness/dizziness, you need a Dix-Hallpike maneuver or supine roll test to diagnose BPPV 4. The evidence provided focuses on lateral canal BPPV treatment maneuvers, but these are only relevant if positional testing confirms BPPV rather than orthostatic hypotension 4.

Immediate Management Steps

If orthostatic hypotension is confirmed:

1. Review all medications with your physician—stop or reduce alpha-blockers, sedatives, prostate medications, and unnecessary blood pressure drugs 2

2. Implement physical counterpressure maneuvers when symptoms occur: leg crossing, squatting, arm tensing to acutely raise blood pressure 2

3. Lifestyle modifications:

   • Increase salt and water intake 3
   • Wear compression stockings 3
   • Sleep with head elevated 3
   • Avoid prolonged standing, hot environments, and large meals 2

4. Pharmacologic treatment if lifestyle measures fail:

   • Midodrine 10 mg three times daily (morning, midday, late afternoon—not after 6 PM) increases standing blood pressure by 15-30 mmHg within 1 hour 5, 3
   • Fludrocortisone as alternative 3

When to Seek Urgent Evaluation

Get a 12-lead ECG to detect arrhythmias, conduction abnormalities, or structural heart disease 2

Seek immediate care if:

• You have actual syncope (complete loss of consciousness) 4
• Symptoms occur with chest pain, severe headache, or neurological deficits 4
• You have suspected neck, back, hip, or pelvis injuries 4

Special Considerations

If neurogenic orthostatic hypotension is suspected (heart rate increase <15 bpm), you need referral for autonomic function testing to evaluate for Parkinson's disease, Pure Autonomic Failure, or Multiple System Atrophy 3. There is often considerable delay in diagnosing autonomic dysfunction, which prevents adequate treatment 3.

Avoid lying flat immediately after standing symptoms—instead, sit down first or assume a position of comfort 4. If you must lie down and are at risk for airway obstruction (decreased alertness, active vomiting), use the recovery position (side-lying) 4.