Postural hypotension, also called orthostatic hypotension, is a drop in blood pressure that happens when you stand up from sitting or lying down. It’s formally defined as a sustained fall of at least 20 mmHg in systolic pressure or 10 mmHg in diastolic pressure within three minutes of standing. That sudden drop reduces blood flow to your brain, which is why you feel dizzy, lightheaded, or unsteady on your feet.
It’s remarkably common, especially with age. A meta-analysis of older adults found a pooled prevalence of about 28% in the general older population and 35% in geriatric outpatients. While a brief moment of lightheadedness after standing may seem harmless, persistent postural hypotension carries real risks, from falls and fractures to long-term cardiovascular problems.
How Your Body Normally Handles Standing Up
When you go from lying down to standing, gravity pulls roughly 300 to 800 mL of blood into your legs and abdomen. Your body has a built-in correction system: pressure sensors in the walls of major arteries near the heart and neck detect the sudden drop in blood flow and fire signals to the brainstem. Within seconds, your nervous system responds by tightening blood vessels and speeding up your heart rate, pushing blood pressure back to normal.
Postural hypotension happens when some part of that reflex fails. The blood pools in your lower body, the corrective response is too slow or too weak, and your brain briefly doesn’t get enough oxygen-rich blood. That failure can stem from medications, dehydration, nerve damage, or any condition that disrupts the signaling chain between your arteries, brain, and blood vessels.
Common Causes
Medications
Medications are one of the most frequent triggers. Several drug classes can interfere with the body’s ability to compensate when you stand:
- Diuretics (water pills) increase sodium loss through urine and reduce blood volume. Loop diuretics also expand the veins, further lowering the amount of blood returning to the heart.
- Blood pressure medications including alpha-blockers, beta-blockers, calcium channel blockers, and nitrates can all blunt the heart rate increase or vessel tightening your body relies on when you stand.
- Antidepressants are a commonly overlooked cause. Tricyclic antidepressants cause postural hypotension in 10 to 50% of patients. SSRIs roughly double the risk, and SNRIs have been linked to a fivefold increase in risk among older adults prone to falls.
The risk is highest when starting a new medication, increasing a dose, or combining multiple drugs that each lower blood pressure in different ways.
Medical Conditions
Several diseases can damage the nerves that control blood pressure regulation. Parkinson’s disease, Lewy body dementia, multiple system atrophy, pure autonomic failure, and amyloidosis all disrupt the autonomic nervous system’s ability to tighten vessels on demand. Diabetes is another major cause because long-term high blood sugar damages the small nerve fibers responsible for blood pressure signaling.
Endocrine problems play a role too. Thyroid disorders, adrenal insufficiency (Addison’s disease), and low blood sugar can all contribute. And straightforward dehydration, whether from illness, heat, or simply not drinking enough water, reduces blood volume enough to trigger symptoms in many people.
Symptoms Beyond Dizziness
The classic symptom is lightheadedness within seconds to a couple of minutes after standing. But postural hypotension can also cause blurred or tunneled vision, mental fogginess, nausea, general weakness, and a distinctive aching pain across the back of the neck and shoulders (sometimes called “coat-hanger pain,” because it follows the shape of a coat hanger across the trapezius muscles). In more severe cases, the blood pressure drop is large enough to cause fainting.
Some people notice symptoms are worse in the morning, after meals, after exercise, or in hot weather, all situations where blood is already being diverted away from the brain. Others have the condition without any noticeable symptoms at all, which is why it’s often caught during a routine check rather than reported by the patient.
How It’s Diagnosed
The test is straightforward. The CDC protocol calls for lying down for five minutes, then having blood pressure and pulse measured. You then stand up, and blood pressure is measured again at one minute and three minutes. A drop of 20 mmHg systolic or 10 mmHg diastolic, or experiencing lightheadedness or dizziness during the test, is considered abnormal. In a clinical setting, a tilt table (which tilts you from flat to a 60-degree angle) can be used when a patient can’t stand on their own.
Because blood pressure naturally fluctuates, your provider may repeat the test at different times of day or under different conditions to confirm a consistent pattern.
Why It Matters Long Term
The immediate danger is falling. A sudden loss of balance or consciousness while standing puts you at risk for head injuries, hip fractures, and other trauma, particularly if you’re older or live alone.
But the risks extend beyond falls. A retrospective cohort study found that people with sustained postural hypotension (a persistent drop that doesn’t correct itself) had a mortality rate of nearly 16%, compared to about 3.5% in people without it. Even the initial, transient form of postural hypotension more than doubled the risk of major cardiovascular events like heart attack and stroke. These associations held even after adjusting for other health factors, suggesting the blood pressure instability itself contributes to cardiovascular damage over time.
Lifestyle Strategies That Help
For mild to moderate cases, behavioral changes are the first line of defense and often enough on their own.
Staying well hydrated is the simplest intervention. Drinking water before long periods of standing, or before activities that tend to trigger symptoms, helps maintain blood volume. Increasing salt intake can also raise blood pressure, though this needs to be balanced carefully since too much salt creates its own cardiovascular risks.
Physical counter-maneuvers can abort symptoms in the moment. If you feel lightheaded after standing, try squeezing your thigh muscles together, clenching your abdominal and buttock muscles, squatting briefly, marching in place, or rising onto your tiptoes. These movements push pooled blood back toward your heart. Before sitting up from bed in the morning, flexing your calf muscles a few times can prime your circulation.
Other practical habits include standing up slowly and in stages (sit on the edge of the bed before standing), avoiding prolonged standing in one position, sleeping with the head of your bed slightly elevated, and wearing compression stockings that reduce blood pooling in the legs. If a medication is contributing, adjusting the dose or timing, such as taking a blood pressure pill at bedtime rather than in the morning, can sometimes resolve the problem.
When Medications Are Needed
When lifestyle measures aren’t enough, a few prescription options can help. Midodrine works by tightening blood vessels, directly raising standing blood pressure. Droxidopa is converted into a stress hormone in the body that constricts blood vessels and is specifically used for postural hypotension caused by nerve damage. Fludrocortisone takes a different approach: it helps the kidneys retain salt and water, expanding blood volume so there’s more to circulate when you stand.
Each of these has trade-offs. Midodrine can raise blood pressure too much when lying down, so it’s typically not taken close to bedtime. Fludrocortisone can cause fluid retention and potassium loss. The choice depends on the underlying cause, symptom severity, and what other medications you’re already taking.