In an August 2025 webinar hosted by the Multiple System Atrophy Center of Excellence at Stanford, Stanford’s Movement Disorders Center, and Brain Support Network, Stanford autonomic disorders neurologist Dr. Mitchell Miglis provided a crucial overview of orthostatic hypotension (OH). Understanding and managing OH is vital, as it is a major contributor to falls and can significantly impact your daily quality of life. Read on for some key highlights and detailed notes.
Orthostatic hypotension is incredibly common, affecting about 50% of people with Parkinson’s disease and over 75% with MSA and LBD.
While the classic symptom is feeling lightheaded or dizzy upon standing, Dr. Miglis emphasized that the signs can often be more subtle. Be on the lookout for these symptoms, especially if they worsen when you are upright and get better when you sit or lie down:
- Fatigue or a feeling of weakness
- Trouble thinking or concentrating (“brain fog”)
- Shortness of breath
- Dimming or blurred vision
- “Coat Hanger” Pain: A distinct cramping pain across the neck and shoulders.
Importantly, many people with OH have no symptoms at all. Even without symptoms, the condition can still increase the risk of falls, making it essential to screen for.
Here’s how to do it:
- Get a Baseline: Lie down flat and rest for a few minutes, then measure your blood pressure.
- Stand Up: Stand up and remain still.
- Check your blood pressure immediately upon standing, and then again after standing still for three minutes.
- Check the Numbers: If the top number (systolic pressure) at the three-minute mark is 20 points or more lower than your measurement when lying down, it is considered abnormal.
Dr. Miglis recommends keeping a log of these measurements for a week to show your doctor. This data is incredibly valuable for getting a proper diagnosis and treatment plan. You can download a printable Orthostatic Log from the Stanford Autonomic Disorders Program website to help you track your numbers.
Managing OH often starts with non-medication strategies like increasing fluid and salt intake, using compression garments, and elevating the head of your bed. For a deeper dive into these strategies and medication options, you can watch a recording of Dr. Miglis’s full presentation on the Stanford APDA YouTube channel.
Here are my full notes on the webinar:
– Elizabeth
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“Orthostatic Hypotension in Parkinsonian Syndromes: Parkinson’s, Multiple System Atrophy, and Lewy Body Dementia”
Speaker: Mitchell Miglis, MD, autonomic disorders specialist, Stanford
Moderator: Candy Welch, Brain Support Network’s MSA Caregiver Support Group
Webinar Hosts:
Multiple System Atrophy Center of Excellence at Stanford
Stanford Movement Disorders Center
Brain Support Network
Webinar Date: August 14, 2025
Summary by: Elizabeth Wong, Stanford Parkinson’s Community Outreach
What is Orthostatic Hypotension (OH)?
Orthostatic hypotension (OH) is a medical term for a drop in blood pressure that occurs when moving to an upright position (e.g., standing up).
Normally, when we stand, the body has a complex reflex circuit that senses a shift of blood to the lower extremities and signals blood vessels to squeeze, pushing blood back up to the brain. Up to a liter of blood can shift downward. In neurodegenerative disorders like Parkinson’s disease (PD), Lewy body dementia (LBD), and multiple system atrophy (MSA), the nerves involved in this reflex degenerate and cannot signal properly. Deposits of abnormal proteins damage parts of the brain and nerves, preventing them from triggering the necessary vessel constriction. As a result, blood pressure drops below normal thresholds.
A blood pressure (BP) drop is diagnosed as OH if the top number (systolic) drops by more than 20 points after standing for at least three minutes. In severe cases, it can drop by 100 points or more. Looking at the systolic number is more reliable than diastolic (bottom number) for correlating with symptoms.
How to measure OH at home:
- Lie flat and rest. Measure blood pressure.
- Stand up.
- Measure blood pressure immediately upon standing and again at 3 minutes of standing.
If systolic BP at 3 minutes is ≥20 points lower than lying flat, it’s abnormal.
Common Symptoms of OH
It is important to note that OH can be symptomatic or asymptomatic. The treatment goal is to manage symptoms, not just the numbers. Symptoms are often vague and can include:
- Lightheadedness or dizziness (a sense of wooziness, not spinning vertigo)
- Dimming or blacking out of vision
- Shortness of breath
- “Coat Hanger” Pain: A cramping pain in the large muscles of the neck and shoulders due to decreased blood flow.
- Fainting (syncope)
- Trouble thinking or fatigue, especially when upright for long periods.
Causes of OH: Neurogenic vs. Non-Neurogenic
Non-Neurogenic (Not a primary neurological cause):
- Medications: This is the most common cause. Antihypertensives, some antidepressants, Viagra®, and even levodopa can lower blood pressure.
- Aging: OH is more common after 50 years; affecting over 20% of those over age of 65 due to loss of muscle mass (less “pump” for blood return), and varicose veins (vein walls weaken).
- Other medical conditions: Dehydration, anemia, heart failure, adrenal insufficiency (rare).
Neurogenic (Caused by a neurological disorder):
- This is due to the breakdown of the autonomic nerves that release norepinephrine, the chemical that tells blood vessels to constrict.
- Affects about 50% of people with PD and over 75% with MSA and LBD.
- OH can be a very early feature of these conditions, sometimes appearing years or decades before motor symptoms.
OH increases risk of:
- Falls
- Hospitalization
- Early mortality
- Disability
- Higher healthcare costs (about 2.5x more)
It may appear years before other motor symptoms in Parkinson’s or MSA, making it an early warning sign.
Evaluation
- Blood count (anemia)
- Electrolytes
- Thyroid
- B12
- Medication review: antihypertensives, tricyclic antidepressants, Viagra®, trazodone, mirtazapine, levodopa—many lower BP.
- Heart rate response: In non-neurogenic OH, heart rate increases significantly when BP drops. In neurogenic OH, it doesn’t rise enough due to nerve degeneration.
Supine Hypertension
A related and equally important issue is supine hypertension, where blood pressure becomes very high when lying flat. Because the body’s blood pressure regulation system is broken, it can’t bring the pressure down when it’s too high. This is common at night and can be harmful to the heart and kidneys over time. A 24-hour blood pressure monitor can be used to assess this.
Non-Medication Treatments of OH (First Line of Defense)
- Elevate the Head of the Bed: Raising the head of the bed by 30 degrees helps lower blood pressure at night (supine hypertension) and prevents it from dropping as severely the next morning. An adjustable bed is often more comfortable than a wedge pillow.
- Compression Garments: Over-the-counter athletic knee-high socks are a good starting point. Waist-high compression or an abdominal binder (a Velcro® wrap for low back pain) can be even more effective, as it prevents blood from pooling in the large vessels of the abdomen.
- Fluid and Salt: Aim for at least 2 liters (64 ounces) of water a day. Increase salt in your diet (if approved by your doctor) to help your body retain water.
- Water Bolusing: To treat acute symptoms, quickly drink 250 to 500 milliliters of cold water (with no electrolytes, such as salt). This can boost blood pressure by 20-30 points for about an hour.
- Exercise: Physical conditioning is very important. Focus on seated or recumbent exercises like a stationary bike, rowing machine, or water aerobics. The pressure of the water in a pool naturally helps support blood pressure. Avoid treadmills, as fainting is a risk.
- Physical Counter-Maneuvers: If you feel faint, sit or lie down immediately. If that’s not possible, cross your legs, squeeze your leg muscles, or squat down.
Medication Treatments (Second Line)
If non-medication treatments are not sufficient, several medications can be used. A critical rule is to not take short-acting OH medications within 3 hours of bedtime to avoid high blood pressure while lying down.
- Midodrine: A short-acting drug (lasts 2-3 hours) that directly constricts blood vessels. Good for taking 30 minutes before an activity known to lower BP (like exercise or a meal). The problem with midodrine is that it does not stimulate the receptors just on the blood vessels, there are receptors in other parts of the body including in a bladder and hair fibers in the skin. A common problem with midodrine is people can have bladder spasms and make urinary retention worse which can contribute to more urinary tract infections, it is not very common, but it can be an issue. Another common side effect is that it can cause a goosebump feeling or itchiness in the skin, especially the scalp.
- Droxidopa (Northera®): Also short-acting and works by converting to norepinephrine. It has fewer side effects than Midodrine (less bladder spasm or skin itchiness).
- Fludrocortisone: A long-acting drug that helps the kidneys retain salt. It is not ideal for those with severe supine hypertension. This is usually only given in the morning because it is long-acting. This can cause swelling because of fluid retention, so people can get swelling in their ankles. It is not something you should use if you have heart failure or major kidney disease.
- Pyridostigmine (Mestinon®): A safe, well-tolerated drug that can be effective and has fewer side effects. This medication increases a chemical called acetylcholine and stimulates the release of norepinephrine that will cause constriction of the blood vessels. Side effects are usually gastrointestinal related because it speeds up the movement of the stomach and the gut.
- Atomoxetine: Typically used for ADHD, but at low doses can be effective for OH when other drugs have failed. This increases the norepinephrine in the nerve area. Since it has a little bit of stimulant effects, it can also help some with brain fog or fatigue. The side effects can be headache or decreased appetite or insomnia.
Conclusion
Everyone with conditions like Parkinson’s should be aware of orthostatic hypotension because it is so common and the symptoms can be subtle and are not limited to just lightheadedness.
How to Check for OH at Home:
- Observe Your Symptoms: Pay close attention to any symptoms that get much worse when you are standing and improve when you sit or lie down.
- Measure Your Blood Pressure: If you notice a trend, begin tracking your blood pressure at home.
- First, lie flat for a few minutes and take a baseline measurement.
- Next, stand up and remain in place for at least three minutes.
- Check your pressure immediately upon standing and then again after the three minutes are up.
- Analyze the Results: If the top number (systolic pressure) is more than 20 points lower after three minutes of standing compared to when you were lying down, this is considered abnormal.
- Keep a Log: Track these measurements at least once a day for a week and bring the log to your doctor to discuss the findings.
Question and Answer
Q: My husband has Lewy body. He’s had OH for a while, but recently, he will suddenly feel weak while already standing and collapse unless he can sit down. Is this the same thing?
A: Probably. It could also be a fainting reflex (vasovagal syncope), where the blood pressure drops very quickly. The only way to really tell is with a tilt table test. But either way, when he sits down, check his blood pressure. If it’s low, you can treat that. Keep a diary of what the pressure is when these episodes happen.
Q: You mentioned taking Midodrine before exercise. Do you advise taking a short-acting medication before eating or sitting on the toilet?
A: Eating, yes. If you get really lightheaded after you eat, you can take a Midodrine about thirty minutes beforehand. For bowel movements, it’s usually not done because it can be difficult to time it thirty minutes in advance.
Q: Are periodic medication adjustments for OH needed as the disease progresses? Do you eventually run out of medication options?
A: Yes, it can happen. As the disease progresses, this can and often does get worse, so we’ll need to make adjustments and go up on doses. Also, sometimes the body’s receptors get less sensitive to the medication. If you’re on maximum doses and it’s not working, you might want to think about taking a break from the medication for a week or so and then restarting it to “reset” the receptors.
Q: How do these medications affect OH: amantadine, Sinemet®, and modafinil?
A: Amantadine, I don’t think it does too much to blood pressure.
Sinemet® lowers blood pressure; you might want to check your pressure 30 minutes after taking it to see how much it drops.
Modafinil is a stimulant and increases blood pressure a little bit, which can be a good thing.
Q: Is OH more severe in MSA than in Parkinson’s or Lewy Body Dementia?
A: Yes
Q: Can you talk about carbidopa/levodopa dosing times? I am finding that eating more carbohydrates for breakfast causes OH episodes, and taking levodopa before breakfast causes more OH in the morning.
A: Drugs like midodrine and droxidopa will peak in about half an hour and stay in your body for three hours. If you want the maximum effect of the drug, take it about half an hour before you do whatever it is that drops your pressure (like eating or taking levodopa). For people with severe OH in the morning, we tell them to have the pill and water on the nightstand and take it 15 minutes before they even get out of bed.
Q: Do high-carbohydrate meals affect blood pressure?
A: Yes. Simple carbohydrate meals are the ones that will cause more blood flow to your stomach and will drop your pressure. You want to limit simple carbohydrates and eat more complex carbs and have more protein with your meal.
Q: My family member passes out often. When should I go to the ER, if ever?
A: Maybe only the first time. Fainting itself isn’t dangerous. Unless you hit your head or there’s another injury, there’s not really a reason to go to the emergency department, especially if you know that you have orthostatic hypotension.
Q: Are primary care physicians familiar with these medications, or would a neurologist be the doctor to prescribe them?
A: Some primary care doctors are, but usually, it’s cardiologists or movement disorder neurologists. Even general neurologists don’t prescribe these a lot.
Q: My blood pressure drops 40+ points when standing. I also have a swallowing problem and have trouble drinking. Any suggestions?
A: If you can’t swallow pills, the options are limited. I have prescribed IV saline boluses for some patients; getting a liter of saline once a week can be effective if you really can’t drink water or take pills, but you have to convince your doctor. Otherwise, it’s just those counter-maneuvers I talked about.
Q: How often does OH appear before motor symptoms in Parkinson’s or MSA, and what are the early red flags?
A: Red flags of a neurodegenerative disorder would be loss of smell and acting out your dreams (RBD behaviors). In MSA, autonomic symptoms tend to happen pretty early on. In Parkinson’s, it often comes on later. Then there’s a third form where people have just orthostatic hypotension for years or decades; about 30% of those people can go on to develop Parkinson’s, MSA, or Lewy Body Dementia over 10 to 15 years.
Q: Is lack of sweating one of those early flags too?
A: Yes, it is. In both MSA and Parkinson’s disease, loss of sweating can be a flag.
Q: What are the brain circuits involved in orthostatic hypotension?
A: The baroreflex is the main reflex. There are sensors in the carotid artery and aortic arch that sense pressure changes. When pressure drops, they send a signal to the brainstem, which initiates a reflex back down through the spinal cord to the autonomic nerves, stimulating the release of norepinephrine to raise blood pressure and heart rate. In neurogenic OH, this signaling system isn’t working.
Q: I had OH years before I was diagnosed with Parkinson’s, but my doctor never tested for it. Do you think I could have had PD years before being diagnosed?
A: Definitely. You probably had the disease process going on. The diagnosis of Parkinson’s is still based on the neurological exam and motor symptoms, but a drop in blood pressure without any other obvious cause is not normal and is definitely associated with the early development of these Parkinson’s conditions
Q: What are your thoughts on skin biopsy markers for predicting progression?
A: Right now, no. The data tells us it’s helpful to distinguish non-neurogenic causes from neurogenic ones, but it’s not helpful to inform prognosis. We know that in the neurogenic OH population, the skin biopsy is positive in over 95% of cases of PD and LBD, and over 80% in MSA. I would only do it if the diagnosis is not clear, which is more common in MSA.
Q: Is it common for someone with Lewy Body and nOH to also experience episodes of hypertension from time to time, not just when supine?
A: Yes, that can happen. Those baroreceptors are just not working, so sometimes you’ll get labile (fluctuating) blood pressure. It can be tricky, but in these cases, sometimes we’ll give a short-acting antihypertensive medication right before bedtime.
Q: You said OH is more severe in MSA. What exactly does that mean?
A: The drops are more severe, it drops lower, and it’s also more refractory to the medication—it’s just harder to treat. I don’t think that the brain responds as well in MSA as it does in Parkinson’s to these drugs.
Q: Is a tilting wheelchair helpful for people with OH?
A: Only if you pass out when you’re sitting. Most people don’t faint if they’re sitting, so if you don’t have severe symptoms while sitting, you shouldn’t need that.
Q: My husband has CBD. When he lies down, he’s clear-headed. When he sits up, he’s mentally confused. Could this be related to blood pressure?
A: It could be. CBD doesn’t have a strong association with OH, but it can happen. If there are any symptoms that are orthostatic (related to posture), it’s very simple to do orthostatic blood pressures. You can find an “orthostatic log” on the Stanford Autonomic website to track pressures for a week and show them to your doctor.
[Editor’s Note: See link above.]
Q: If someone has an MSA diagnosis, do they always have OH? Does it go away?
A: It doesn’t go away, but people can get more or less symptomatic over time. I think the brain adapts and people adapt to it. The disease doesn’t just go away, unfortunately.