Written by Jose-Alberto Palma, MD, PhD and Horacio Kaufmann, MD
Neurogenic orthostatic hypotension (nOH) is a condition that is part of a larger category called orthostatic hypotension (OH), which is also known as postural hypotension. nOH is caused by dysfunction in the autonomic nervous system and causes people to feel faint when they stand or sit up. Learn more about nOH in the first part of our article.
The good news is that there is treatment for neurogenic orthostatic hypotension. The goal of treatment is not to achieve normal blood pressure values, but rather, to reduce symptoms of nOH and improve your quality of life.
Management of nOH includes three components:
- Correcting aggravating factors
- Lifestyle changes
Stopping medications that can reduce blood pressure, such as diuretics, anti-hypertensives, some medications used for prostate and urinary symptoms, medications for erectile dysfunction, medications for angina and some antidepressants is a first step. Levodopa (Sinemet®) can lower blood pressure, and adjusting dosage may be necessary in people with Parkinson’s and nOH. Anemia (a condition where you have low levels of hemoglobin, iron, in your blood) can aggravate nOH and should be investigated and treated accordingly.
Symptoms of nOH can improve with time, patience and non-pharmacological changes. It is tempting to try to control nOH only with medications; however, this approach is less effective and may have adverse side effects. Treatment of nOH is more successful if lifestyle changes are also made.
Below are lifestyle steps you can take to improve symptoms of nOH. You can adopt all of them at the same time. If performed properly, these actions can lead to a dramatic improvement, even without medications.
1. Increase water intake.
People with nOH need more water and should be drinking 3 quarts per day (~2.5 liters). Ideally, the best approach is to drink water and supplement it with salt (see Tip #2). Diet (sugar-free) beverages are also acceptable. Tea and coffee increase urine output, so they may worsen your symptoms. Sports drinks, juices and non-diet beverages are not recommended, due to their high-sugar content (see Tip #8).
2. Increase salt intake.
Be sure to discuss adding salt to your food with your doctor, but increasing salt in your meals will help to increase your blood pressure. Most people do not need to take salt tablets, and in fact, salt tablets can cause abdominal discomfort in some people.
3. Wear compression stockings (also known as TED stockings).
You can find compression stockings in medical supply stores. Wearing them will reduce the venous pooling that occurs when standing up and, therefore, will increase your blood pressure when standing. There are several “strengths” or “levels” of compression stockings. At first, you can try a medium strength (i.e, 20-30 mmHg). To be useful, compression stockings should be worn up to the abdomen. Knee-high stockings are not effective. You do not need to wear the stockings while sleeping.
4. Wear an abdominal binder (i.e., a Velcro belt around your belly).
You can find this item in medical supply stores and it functions in a similar way to compression stockings. You do not need to wear this while you sleep.
5. Sleep with the head of your bed raised by at least 30º (ideally 45-50º).
Elevating the head of your bed is useful because people with nOH frequently have supine hypertension (i.e., high blood pressure when lying down). To avoid supine hypertension, people should never lay completely flat. Sleeping with the head of the bed raised will also reduce urine output, causing fewer nighttime urinations and improved blood pressure in the morning. The best way to raise the head of the bed is to get an electric bed or an electric mattress. These are commercially available in several sizes. Other, less effective ways to increase the head of the bed include using a wedge, or putting books/bricks under the upper feet of the bed.
6. Drink 16 oz. of cold water 30 minutes before getting out of bed in the morning.
This will increase your blood pressure when you get up. Drinking 16 oz. of cold water at any time of day will also increase your blood pressure. You can do this on an as-needed basis, ensuring that you drink the recommended total (see #1) of about 3 quarts per day of liquids.
7. Start a physical therapy program.
Physical exercise will decrease blood pressure; however, exercise is crucial to keep muscles active and for overall well-being. In order to avoid low blood pressure when exercising, your physical therapist can recommend recumbent exercises (e.g., recumbent bicycle, elastic bands, rowing machine, etc.). The best and safest exercises for those with nOH are those performed in a swimming pool. The hydrostatic pressure of the water will prevent your blood pressure from falling dramatically, even if you are standing, as long as most of your body is underwater (with your head out, of course, so that you continue to breathe). While you are in the water, you will feel better and be able to exercise without significant symptoms. The better your baseline fitness, the less intense your symptoms of nOH will be. Therapies such as yoga and tai chi are also highly advisable.
8. Avoid factors that decrease blood pressure and worsen nOH.
- Hot and humid temperatures
- Physical exercises which cause blood pressure drop (see Tip #6)
- Dehydration (see Tip #1)
- High-glycemic index carbohydrates. Try to reduce high-glycemic carbohydrates in your meals. Try eating several small meals (5-6) instead of the three traditional meals a day.
High-glycemic carbohydrates to reduce or avoid:
Low-glycemic index carbohydrates to include:
9. Be aware of your symptoms.
If you experience symptoms of nOH, you will find relief by performing physical counter-maneuvers, such as making a fist, crossing your legs or clenching your buttocks, which increase your blood pressure when you are standing. If these counter-maneuvers are not enough, sit or lie down quickly to avoid fainting and injury.
While lifestyle changes can be very effective for managing nOH when performed properly, many people still require medication to manage symptoms. Two complementary strategies are used when it comes to medication: a) fludrocortisone for long-term increase in water and salt retention; and, b) midodrine or droxidopa for short-term increase in blood pressure.
All available drugs that raise blood pressure in the standing position also raise blood pressure while lying down, therefore increasing the risk or worsening hypertension while lying flat with your face up. Although there are no specific data on cardio- and cerebrovascular events induced by hypertension in the flat position, physicians treating people with nOH should be aware of this potential side effect. Before beginning treatment with any of the above medications, your doctor should carefully review your other medications.
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Dr. Jose-Alberto Palma is Assistant Professor of Neurology and Assistant Director of the Dysautonomia Center at New York University. His work over the past years has been focused on the diagnosis, management and understanding on autonomic disorders in patients with autonomic synucleinopathies, such as Parkinson disease and multiple system atrophy, as well as in the search for biomarkers for early diagnosis of these disorders. He has been involved in several studies and clinical trials to develop new treatments for autonomic dysfunction, and to describe the premotor phase of Parkinson disease.
Dr. Horacio Kaufmann is Professor of Neurology and Medicine and the Director of the Dysautonomia Center at New York University. He is one of the world leading experts in the diagnosis and management of patients with autonomic synucleinopathies (Parkinson disease and multiple system atrophy), a subject that has been the focus of his research and academic career over the last 25 years. He has extensive experience as the principal investigator of national and international studies on autonomic dysfunction, including clinical trials for orthostatic hypotension, and identification and development of biomarker for early diagnosis and progression of Parkinson disease and related disorders.