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Orthostatic hypotension

Last reviewed: 4 Sep 2023
Last updated: 01 Jun 2022



History and exam

Key diagnostic factors

  • older adult age
  • use of high-risk medications
  • underlying medical condition
  • postural lightheadedness, syncope, and other symptoms of cerebral hypoperfusion
More key diagnostic factors

Other diagnostic factors

  • parkinsonian features
  • cerebellar ataxia
  • weight loss
  • resting tachycardia or impaired heart rate variation
  • abnormal gastrointestinal motility
  • erectile dysfunction and lack of ejaculation
  • anhidrosis, heat intolerance, dry skin, focal hyperhidrosis
  • urinary frequency, urgency, nocturia
Other diagnostic factors

Risk factors

  • older adult age
  • frailty and physical deconditioning
  • medications that impair sympathetic tone
  • volume depletion/anemia
  • autonomic neuropathy (e.g., diabetes mellitus)
  • Parkinson disease
  • dementia with Lewy bodies
  • multiple system atrophy
More risk factors

Diagnostic investigations

1st investigations to order

  • posture test
More 1st investigations to order

Investigations to consider

  • tilt-table test
  • plasma norepinephrine
  • deep breathing
  • Valsalva maneuver
  • nerve conduction studies and electromyogram (EMG)
  • quantitative sudomotor axon reflex test (QSART)
  • heart rate variability
  • 24-hour blood pressure monitoring
  • autoimmune antibodies
  • chest CT
  • serum and urine electrophoresis
  • fat-pad biopsy
  • genetic testing
More investigations to consider

Treatment algorithm


all patients



Italo Biaggioni, MD

Professor of Medicine and Pharmacology

Vanderbilt University




IB is a consultant for Theravance Biopharma and has received grant support from NIH, Theravance Biopharma, and Biohaven. IB holds a patent for an automated binder for the treatment of orthostatic hypotension. IB is an author of a number of references cited in this topic.

Lucy Norcliffe-Kaufmann, PhD

Assistant Professor

Dysautonomia Center

Department of Physiology and Neuroscience

NYU Langone Medical Center

New York



LNK is a board member of the American Autonomic Society and has received grant support from Theravance Biopharma, PTC Therapeutics, National Institutes of Health, Michael J. Fox Foundation, and the Familial Dysautonomia Foundation. LNK is an author of a number of references cited in this topic.

Horacio Kaufmann, MD

Professor of Neurology

Medicine and Pediatrics

New York University School of Medicine

New York



HK is editor in chief of Clinical Autonomic Research and serves as principal investigator of a clinical trial sponsored by Biogen MA Inc. HK has received consultancy fees from Lilly USA LLC, Biohaven Pharmaceuticals Inc, Takeda Pharmaceutical Company Ltd, Ono Pharma UK Ltd, Lundbeck LLC, and Theravance Biopharma US Inc. HK is an author of a number of references cited in this topic.

Peer reviewers

Phillip A. Low, MD

Robert D. and Patricia E. Kern Professor of Neurology

Mayo Clinic College of Medicine




PAL is an author of a reference cited in this topic.

William P. Cheshire, MD

Professor of Neurology

Mayo Clinic




WPC declares that he has no competing interests.

Alan Moore, MB, FRCPI

Consultant Geriatrician

Beaumont Hospital




AM has received payment from Shire Pharmaceuticals, manufacturer of midodrine, for providing educational talks, and the department in which he works has received unrestricted educational grants from Shire Pharmaceuticals.

  • Differentials

    • Neurally mediated (vasovagal) syncope
    • Vertigo
    • Nonspecific falls in older people
    More Differentials
  • Guidelines

    • Consensus statement on the definition of neurogenic supine hypertension
    • Guidelines on the diagnosis and management of syncope
    More Guidelines
  • Patient leaflets

    Postural hypotension (low blood pressure when you stand up)

    More Patient leaflets
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