What Orthostatic Hypotension Feels Like
Orthostatic hypotension typically causes dizziness, lightheadedness, weakness, and visual disturbances that develop upon standing and are relieved by sitting or lying down. 1
Core Symptoms
The European Society of Cardiology guidelines describe a characteristic constellation of symptoms that occur when blood pressure drops upon standing:
Most Common Symptoms
- Dizziness and lightheadedness - the hallmark sensations that occur as cerebral perfusion decreases 1
- Pre-syncope (feeling like you're about to faint) or actual syncope (fainting) 1
- Weakness, fatigue, and lethargy - generalized feelings of physical depletion 1
- Palpitations - awareness of heartbeat, though this may refer to sinus tachycardia rather than abnormal rhythms 1
Visual and Sensory Disturbances
- Visual changes including blurring, enhanced brightness, loss of color perception, tunnel vision, and ultimately complete loss of vision if severe 1
- Hearing disturbances such as impaired hearing, crackles, tinnitus, or sounds seeming distant 1
Distinctive Pain Patterns
- "Coat hanger pain" - characteristic pain in the neck (occipital/paracervical) and shoulder region 1, 2
- Low back pain or precordial (chest) pain, particularly in cases of autonomic failure 1
Autonomic Symptoms
- Pallor, sweating, and nausea - reflecting autonomic nervous system activation 1
Timing and Triggers
Symptoms characteristically develop upon standing, are relieved by sitting or lying down, and tend to be worse under specific conditions: 1, 3
- Morning hours - symptoms often most severe after waking 1
- After meals - postprandial hypotension exacerbates symptoms 1
- Heat exposure - warm environments worsen the blood pressure drop 1
- After exertion - physical activity can precipitate symptoms 1
Clinical Patterns by Type
The timing of symptom onset helps distinguish different forms:
Classical Orthostatic Hypotension
- Symptoms begin 30 seconds to 3 minutes after standing 1
- Blood pressure drop starts immediately and then stabilizes at a lower level 3
- Sustained low blood pressure may persist for many minutes 3
- Symptoms include dizziness, pre-syncope, fatigue, weakness, palpitations, and visual/hearing disturbances 1
Initial Orthostatic Hypotension
- Symptoms occur within 0-30 seconds of standing 1
- Primarily lightheadedness/dizziness and visual disturbances 1
- Rapid onset and typically brief duration 1
Delayed (Progressive) Orthostatic Hypotension
- Symptoms develop 3-30 minutes after standing 1
- Prolonged prodrome with gradual worsening of dizziness, fatigue, weakness, palpitations, visual and hearing disturbances, excessive sweating, low back pain, neck pain, and precordial pain 1
- Frequently followed by rapid syncope 1
Important Clinical Distinctions
The symptom pattern differs from vasovagal syncope: In orthostatic hypotension, the blood pressure drop starts immediately upon standing and stabilizes low, whereas in vasovagal syncope, the blood pressure drop starts several minutes after standing and accelerates until fainting occurs. 1
Symptoms may be absent: Classic orthostatic hypotension can be asymptomatic, with symptoms depending more on the absolute blood pressure level reached than the magnitude of the fall. 3 This is particularly important because asymptomatic orthostatic hypotension still carries increased cardiovascular risk and mortality. 3
Severity Spectrum
Symptoms range from mild (slight dizziness with quick recovery) to severe (complete syncope with loss of consciousness). 1 The presence of coat hanger pain and sustained symptoms despite sitting suggests more severe autonomic dysfunction. 1