Orthostatic Hypotension

Orthostatic hypotension can be a sign of autonomic disease in a variety of neurologic conditions. The most important first step is to understand what is driving it. In addition to neurologic causes, there can be cardiac causes or adrenal issues.

Testing often involves blood pressure monitoring with standing and laying down. In orthostatic hypotension, blood pressure often drops by 20 mmHg systolic or 10 mmHg diastolic or more. Certain blood tests are frequently done as well as heart tests like an echocardiogram and ECG. A tilt table test allows more frequent measurements and other maneuvers can be added (like a Valsalva or bearing down test).

First line therapy is to try non-medication changes that can increase the standing blood pressure. Compression stockings and abdominal binders prevent fluid from pooling within the body and can help. Raising the head of the bed by 6 inches can increase the resting tone of the blood vessels and help.

When that is not enough, agents that you take to reduce your blood pressure may need to be reduced. When that does not work, a medication called pyridostigmine can be tried. This normally makes a small difference but does so without raising the lying blood pressure.

When those interventions are not enough, midodrine and fludrocortisone (Florinef) can be used to raise both the lying and standing blood pressures. However, these often cause high blood pressure at times. Pyridostigmine (Mestinon) can raise the standing blood pressure a small amount – but this is not always enough to help with symptoms. Droxidopa (Northera) is a newer option for Parkinsons related orthostasis.