In some people, particularly older adults, blood pressure drops excessively when they sit or stand up (a condition called orthostatic or postural hypotension). Symptoms of faintness, light-headedness, dizziness, confusion, or blurred vision occur within seconds to a few minutes of standing (particularly after lying in bed or sitting for a long time) and resolve rapidly when the person lies down. However, some people fall, faint, or very rarely have a brief seizure. Symptoms are often more common and worse after people exercise, have consumed alcohol and/or a heavy meal, or are deficient in fluids (dehydration).
Some younger people experience similar symptoms upon standing but without having a drop in blood pressure. Often, their heart rate increases (tachycardia) more than normal upon standing, so this condition is called postural orthostatic tachycardia syndrome (POTS). The reason why such people feel dizzy despite having normal blood pressure is not clear.
Causes of Dizziness or Light-Headedness When Standing Up
Dizziness or light-headedness when standing up occurs as a result of abnormal blood pressure regulation. Normally, when people stand, gravity causes blood to pool in the veins of the legs and trunk. This pooling lowers the blood pressure and the amount of blood the heart pumps to the brain. Low blood flow to the brain causes the dizziness and other symptoms. To compensate, the nervous system quickly increases the heart rate and constricts blood vessels, which rapidly returns blood pressure to normal before symptoms can develop. The part of the nervous system responsible for this compensation is the autonomic nervous system.
Many disorders can cause problems with blood pressure regulation and lead to dizziness when standing up. Categories of causes include
Malfunction of the autonomic nervous system due to disorders or medications
Decreased ability of the heart to pump blood
Decreased blood volume (hypovolemia)
Faulty hormonal responses
Causes differ depending on whether symptoms are new or have been present for some time.
Common causes
The most common causes of new dizziness when standing up include
Decreased blood volume (as may result from dehydration or blood loss)
Medications
Prolonged bed rest
An underactive adrenal gland (adrenal insufficiency)
The most common causes of dizziness when standing up that has been present for a long time (chronic) include
Age-related changes in blood pressure regulation
Medications
Malfunction of the autonomic nervous system
Evaluation of Dizziness or Light-headedness When Standing Up
People who become dizzy or light-headed when standing up often recover quickly when they sit down and then slowly stand again. However, it is usually important to determine what is causing the dizziness. The following information can help people decide when to see a doctor and help them know what to expect during the evaluation.
Warning signs
In people who become dizzy or light-headed when standing up, certain symptoms and characteristics are cause for concern. They include
Blood in the stool or black, tarry stool
Nervous system symptoms such as difficulty walking and/or poor coordination or balance
Falling or fainting (passing out)
Chest pain or discomfort
When to see a doctor
People who have warning signs should seek emergency department care right away. Other people who have frequent or ongoing episodes of dizziness upon standing should see a doctor as soon as possible. People who have only an occasional episode of dizziness upon standing should call their doctor. The doctor will decide whether and how quickly to see the person depending on the other symptoms and medical history.
What the doctor does
The doctor first asks questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the dizziness and the tests that may need to be done.
Doctors ask
How long the dizziness has been occurring
Whether the person has fainted or fallen during an episode of dizziness
Whether the person has experienced conditions that are known to cause dizziness (such as bed rest or fluid loss)
Whether the person has a disorder (such as diabetes, Parkinson disease, or a cancer) that may cause dizziness
Whether the person is taking a medication (for example, an antihypertensive) that may cause dizziness
The doctor then does a physical examination. The person lies down for 5 minutes, and then the doctor measures the blood pressure and heart rate. Blood pressure and heart rate are measured again after the person stands or sits up for 1 minute and again after standing or sitting for 3 minutes. The doctor may do a digital rectal examination to see whether the person might have some bleeding in the digestive tract. A neurologic examination to test strength, sensation, reflexes, balance, and gait is important.
The most common causes of sudden dizziness—medications, bed rest, and decreased blood volume—are usually obvious. In people with long-term symptoms, findings such as movement problems may indicate Parkinson disease. Numbness, tingling, or weakness may indicate a nervous system disorder.
Some Causes and Features of Dizziness or Light-Headedness When Standing Up
Cause | Common Features* | Tests |
|---|---|---|
Central nervous system† disorders | ||
Muscle stiffness Slow, shaky movements Loss of coordination and/or balance Incontinence or inability to urinate | A doctor's examination Sometimes MRI | |
Muscle stiffness Tremor Slow, shaky movements and a shuffling gait Difficulty walking | Only a doctor's examination | |
Strokes if several have occurred | In people who are known to have had strokes | Only a doctor's examination |
Spinal cord disorders | ||
Syphilis that affects the spinal cord (tabes dorsalis) | Intense, stabbing pains in the legs that come and go Unsteady walking Decreased sensation in the legs and numbness or tingling | Blood tests and sometimes a spinal tap (to obtain cerebrospinal fluid) to check for syphilis |
Tumors | Back pain Muscle weakness and decreased sensation in the legs | MRI |
Peripheral nerve† disorders | ||
Numbness, tingling, and weakness | Biopsy | |
Nerve damage caused by diabetes, excessive alcohol use, or nutritional deficiencies | Often burning pain and/or numbness in the feet and hands Sometimes weakness Usually in people who are known to have a disorder that can cause nerve damage | Nerve conduction testing and electromyography |
Sometimes decreased sweating and intolerance of heat Constipation or loss of control over bowel movements (fecal incontinence) Difficulty emptying the bladder | A doctor's examination Blood tests | |
A decreased volume of blood (hypovolemia) | ||
Thirst, decreased urination, and sometimes confusion | Only a doctor's examination | |
Excessive loss of blood | Often in people who have had an injury or surgery Blood in stool or black, tarry stool | A doctor's examination, including testing stool for blood A complete blood count |
Weakness and fatigue | Blood tests | |
Heart and blood vessel disorders | ||
Sometimes chest pain Palpitations (awareness of heart beats) Fatigue Shortness of breath Symptoms often occur suddenly | ||
Chronic venous insufficiency (causing blood to pool in the legs) | Long-lasting swelling in one or both legs Chronic mild discomfort or aching in the ankles or legs but no pain Sometimes reddish brown, leathery areas on the skin and shallow sores, usually on the lower legs Often varicose veins | A doctor's examination |
Shortness of breath and fatigue | A doctor's examination Usually echocardiography (ultrasound study of the heart) | |
Heart attack (myocardial infarction) | Chest pain or pressure Shortness of breath or fatigue Sometimes in people who are known to have had a recent heart attack | ECG and blood tests to measure substances that indicate heart damage (cardiac biomarkers) |
Shortness of breath Often chest pain or pressure | Echocardiography | |
High levels of the hormone aldosterone (hyperaldosteronism) or catecholamines (pheochromocytoma), usually caused by a tumor in the adrenal gland) | Weakness, tingling, muscle spasms, high blood pressure, and headache | Blood tests |
Drugs | ||
In people known to use one of these medications | A doctor's examination Sometimes stopping the medication to see if symptoms go away | |
Medications that affect the central nervous system: Antipsychotics (particularly phenothiazines), monoamine oxidase inhibitors, or tricyclic or tetracyclic antidepressants | In people known to use one of these medications | Only a doctor's examination Sometimes stopping the medication to see if symptoms go away |
Sedatives: Alcohol, opioids, or barbiturates | In people known to use one of these substances | Only a doctor's examination Sometimes stopping the medication to see if symptoms go away |
In people known to use one of these medications | Only a doctor's examination Sometimes stopping the medication to see if symptoms go away | |
Other problems | ||
Age-related changes in blood pressure regulation | In older adults No other symptoms | Only a doctor's examination |
Bed rest if prolonged | In people who have been at bed rest for a long time | Only a doctor's examination |
A low level of potassium in the blood (hypokalemia) | Muscle weakness and cramping Pins-and-needles sensation Often in people who take certain diuretics | Blood tests |
* Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present. | ||
† The central nervous system includes the brain and spinal cord. The peripheral nervous system includes the nerves outside the brain and spinal cord. | ||
CT = computed tomography; ECG = electrocardiography; MRI = magnetic resonance imaging. | ||
Testing
Unless the cause is obvious (for example, bed rest), testing is usually needed. The doctor usually does electrocardiography (ECG), a complete blood count, and other blood tests (for example, measuring levels of electrolytes). Other tests are done based on what doctors find during the examination, especially if the person's symptoms suggest a heart or nerve problem.
If doctors suspect a medication is causing the dizziness, they may ask the person to stop taking the medication and observe whether the dizziness also stops, thus confirming the cause.
Treatment of Dizziness or Light-headedness When Standing Up
Any causes are treated when possible, including changing or stopping any causative medications. However, many causes cannot be cured, and people must take measures to decrease their symptoms. Measures include lifestyle changes and medications.
fludrocortisone
Essentials for Older Adults: Dizziness or Light-headedness When Standing Up
Dizziness or light-headedness when standing occurs in about 15 to 20% of older adults. It is more common among people with coexisting disorders, especially high blood pressure, and among residents of long-term care facilities. Many falls may result from dizziness when standing. Older adults should avoid prolonged standing.
The increased incidence in older adults is due to decreases in the responsiveness of the receptors that manage blood pressure plus increases in arterial wall stiffness, which make it more difficult for arteries to move more blood to increase blood pressure. Decreases in receptor responsiveness delay the normal heart and blood vessel responses to standing. Paradoxically, high blood pressure, which is more common among older adults, may contribute to poor receptor sensitivity, increasing vulnerability to dizziness when standing.
Key Points
Dizziness or light-headedness when standing typically involves a decrease in body fluid volume or autonomic nervous system dysfunction.
Aging often causes some degree of autonomic nervous system dysfunction, but doctors examine all affected people to ensure that no nervous system disorders are present.
Tilt table testing is a common test of autonomic function.
