Symptoms of Orthostatic Hypotension
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 hallmark symptoms reflect cerebral hypoperfusion and include:
- Dizziness and lightheadedness are the most characteristic sensations, occurring as cerebral perfusion decreases when standing 1, 2
- Visual disturbances progress in severity from blurring and enhanced brightness to loss of color perception, tunnel vision, and ultimately complete loss of vision if severe 1, 3
- Weakness, fatigue, and lethargy represent generalized physical depletion 1, 2
- Pre-syncope (feeling like you're about to faint) or actual syncope (fainting/loss of consciousness) are common presentations 1, 2
Additional Symptoms
Beyond the core symptoms, patients may experience:
- Hearing disturbances including impaired hearing, crackles, tinnitus, or sounds seeming distant 1
- Nausea and palpitations 2
- Headache 2, 3
- Neck and shoulder pain (coat hanger syndrome), low back pain, or precordial chest pain, particularly in autonomic failure 4, 3
- Dyspnea and chest pain as less common manifestations 2, 3
Timing and Triggering Factors
Symptoms follow a characteristic temporal pattern:
- Classical orthostatic hypotension: Symptoms begin 30 seconds to 3 minutes after standing, with sustained low blood pressure that may persist for many minutes 1
- Initial orthostatic hypotension: Occurs within 0-30 seconds of standing, primarily causing lightheadedness/dizziness and visual disturbances 1
- Delayed (progressive) orthostatic hypotension: Develops 3-30 minutes after standing, with a prolonged prodrome and gradual worsening 1
Symptoms are characteristically worse under specific conditions: morning hours after waking, after meals (postprandial hypotension), with heat exposure, and after physical exertion 1, 4
Important Clinical Distinctions
Classic orthostatic hypotension can be asymptomatic—symptoms depend more on the absolute blood pressure level reached than the magnitude of the fall 1, 4. This means a patient with a significant blood pressure drop may have no symptoms if their baseline blood pressure is high enough.
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 drop begins several minutes after standing and accelerates until fainting occurs 1, 4
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.