What is neurogenic orthostatic hypotension?

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What is neurogenic orthostatic hypotension?

Neurogenic orthostatic hypotension (nOH) is a specific type of orthostatic hypotension caused by dysfunction of the autonomic nervous system, which controls blood pressure regulation. It occurs when blood pressure drops significantly upon standing up, due to the inability of the nervous system to properly regulate the constriction of blood vessels and heart rate. This leads to symptoms such as dizziness, lightheadedness, fainting, and fatigue.

What Causes Neurogenic Orthostatic Hypotension?

nOH is typically associated with disorders that affect the autonomic nervous system, particularly the nerves responsible for regulating blood pressure. Some common causes include:

Neurodegenerative Diseases:
- Parkinson’s Disease: One of the most common conditions associated with nOH.
- Multiple System Atrophy (MSA): A rare degenerative neurological disorder.
- Pure Autonomic Failure: A condition where the autonomic nervous system gradually stops working.
Diabetic Neuropathy: Chronic diabetes can damage the nerves that control blood pressure regulation.
Other Neurological Conditions: Certain types of peripheral neuropathy, amyloidosis, or spinal cord injuries can also lead to nOH.

How Neurogenic Orthostatic Hypotension Works

In a healthy individual, the autonomic nervous system adjusts blood pressure when moving from a lying or sitting position to standing by:

Constricting blood vessels to push blood back toward the heart and brain.
Increasing heart rate to maintain adequate blood flow to vital organs.

In people with nOH, these regulatory mechanisms fail due to damaged nerves, causing blood to pool in the lower extremities upon standing. As a result, blood pressure drops significantly, leading to symptoms such as dizziness, blurred vision, and even fainting.

Symptoms of Neurogenic Orthostatic Hypotension

Symptoms usually occur within a few minutes of standing and may include:

Dizziness or lightheadedness
Fainting (syncope)
Blurry vision
Fatigue
Weakness
Neck or shoulder pain (“coat hanger” pain, which is common in neurogenic causes)
Difficulty concentrating
Nausea

Diagnosis of Neurogenic Orthostatic Hypotension

Diagnosing nOH involves confirming a drop in blood pressure upon standing, typically measured as:

A systolic drop of at least 20 mm Hg, or
A diastolic drop of at least 10 mm Hg within 3 minutes of standing.

Tests may include:

Blood Pressure Monitoring: Measuring blood pressure and heart rate while lying down, sitting, and standing.
Tilt Table Test: A specialized test where the patient is tilted at different angles to assess blood pressure response.
Autonomic Function Tests: These can assess how well the autonomic nervous system is working and can help differentiate neurogenic causes from other forms of orthostatic hypotension.

Management and Treatment of Neurogenic Orthostatic Hypotension

Managing nOH involves both lifestyle adjustments and medications to prevent symptoms and improve quality of life. Treatment focuses on raising blood pressure and minimizing symptoms.

Lifestyle Adjustments

Increase Fluid and Salt Intake: Drinking more fluids and increasing salt intake can help raise blood pressure, but this should be done under medical supervision.
Wear Compression Stockings: These help prevent blood from pooling in the legs by promoting blood flow back to the heart.
Slowly Transition to Standing: Avoid standing up too quickly. Move from lying down to sitting, and then stand up slowly to give your body time to adjust.
Raise the Head of the Bed: Sleeping with the head of the bed elevated can help regulate blood pressure overnight and reduce morning hypotension.
Avoid Large Meals: Large meals can divert blood to the digestive system and exacerbate symptoms. Smaller, more frequent meals may help.
Limit Alcohol: Alcohol can lower blood pressure and should be limited or avoided.

Medications

Midodrine: A medication that constricts blood vessels, helping to increase blood pressure.
Fludrocortisone: A mineralocorticoid that helps the body retain salt and water, which increases blood volume and raises blood pressure.
Droxidopa (Northera): A drug specifically approved for the treatment of neurogenic orthostatic hypotension. It increases levels of norepinephrine, a chemical that helps regulate blood pressure.
Pyridostigmine: This medication may help improve blood pressure without excessively increasing blood pressure while lying down (supine hypertension), which is a common issue in nOH treatment.

Complications of Neurogenic Orthostatic Hypotension

If left untreated, nOH can lead to complications such as:

Falls and Injuries: Dizziness and fainting can lead to falls, causing fractures or other injuries.
Reduced Quality of Life: The symptoms of nOH can significantly limit daily activities and independence.
Cognitive Impairment: Chronic low blood pressure may reduce blood flow to the brain, potentially contributing to cognitive issues.

Conclusion

Neurogenic orthostatic hypotension is a form of low blood pressure caused by dysfunction in the autonomic nervous system, often associated with neurodegenerative diseases like Parkinson’s or multiple system atrophy. It results in significant drops in blood pressure upon standing, leading to dizziness, fainting, and fatigue. While it cannot always be cured, effective management through lifestyle changes, medications, and proper monitoring can improve symptoms and quality of life. If you suspect you have nOH, working closely with a healthcare provider for a tailored treatment plan is essential.