Orthostatic Intolerance and the Headache Patient

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Orthostatic intolerance (OI) refers to a group of clinical conditions, including postural orthostatic tachycardia syndrome (POTS) and neurally mediated hypotension (NMH), in which symptoms worsen with upright posture and are ameliorated by recumbence. The main symptoms of chronic orthostatic intolerance syndromes include light-headedness, syncope or near syncope, blurring of vision, headaches, problems with short-term memory and concentration, fatigue, intolerance of low impact exercise, palpitations, chest pain, diaphoresis, tremulousness, dyspnea or air hunger, nausea, and vomiting. This review discusses what is known about the pathophysiology of this disorder, potential treatments, and understanding its role in the patient with chronic headache pain.

Section snippets

Physiological Responses to Upright Posture

With standing, hydrostatic pressure changes lead to a redistribution of blood volume to vessels below the level of the heart. This volume is estimated to be approximately 500 to750 mL in adults and likely approximates this amount in adolescents. Reduced blood return to the thorax leads to a modest (approximately 20%) drop in cardiac output, reduced stretch of arterial baroreceptors, and reduced cerebral blood flow.3, 4, 5, 6 Neural responses mediated by the medullary cardiovascular centers lead

Instantaneous Orthostatic Hypotension

Chronic orthostatic hypotension, as defined by a blood pressure reduction of at least 20 mm Hg systolic or 10 mm Hg diastolic within the first 3 minutes of upright posture,7 is rarely seen in children except when there has been an acute change in blood volume (hemorrhage, dehydration, and adrenal insufficiency), febrile illness, or excessive histamine release. Tanaka et al8 have defined a more common pediatric variant, which they have termed INOH. INOH is defined by orthostatic symptoms for

How Do Our Patients Clinically Present?

Approximately two thirds of adolescent patients are female, and the vast majority of patients are white. OI usually does not present before 9 years of age and more typically affects women between 15 and 50 years of age. Most commonly, it presents in teenagers within a few years of the pubertal growth spurt, and a proportion of patients eventually seem to outgrow their symptoms. OI has been noted to occur more in individuals with hyperextensible joints and known disorders of basic cellular

Diagnostic Testing

It is important to evaluate and exclude secondary causes of OI. Eating disorders with accompanying volume depletion and weight loss must be considered. Furthermore, medications such as diuretics, anxiolytics, and vasodilators that impair venous return to the heart may cause similar symptoms.59, 65 Hyperadrenergic states, anxiety, and volume depletion can lead to postural heart rate increases during tilt table testing. It should be noted that a patient can have one of the previously mentioned

Treatment Options

Treatment options for CDH and for OI have been well described63, 67 and are at least partially effective in most patients for both conditions. The management of OI is largely empiric, based on evidence from small physiological studies, inferences from adult work, and only a small number of randomized controlled trials at any age. Treatment begins with an explanation of the problem and education about avoiding conditions that provoke symptoms. Prolonged sitting, quiet standing, warm

Dizziness and the Headache Patient

CDH patients have multiple symptoms of dizziness. Dizziness and vertigo may occur during severe migrainous headaches which occur in most patients with CDH. The dizziness is associated with feeling weak and unsteady and with blurring or loss of vision. When the dizziness is primarily related to a severe migrainous headache, then improvement will occur once the headache control is improved.

At times, however, patients may notice dizziness between the episodes of severe headaches. This type of

Conclusions

OI and chronic pain, including CDHs, are debilitating disorders in adolescents that are commonly present in the same individual. Prospective studies are still needed to determine what the most effective ways to treat these symptoms are. It is important to recognize and address both of these issues in our patients.

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