The Link Between Migraine and Postural Orthostatic Tachycardia Syndrome (POTS)

If you experience a spike in heart rate when sitting or standing up, you may have POTS. It often goes hand in hand with migraine, but there are essential differences.

There are a number of conditions that often coexist with migraine. One of these is Postural Orthostatic Tachycardia syndrome (POTS).

People with POTS experience a fast heartbeat when transitioning from sitting or lying down. But what does this have to do with migraine?

It turns out these conditions are closely connected, and learning about POTS can help us better understand migraine, too.

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The link between POTS and migraine

As mentioned above, POTS causes the heart rate to increase far more than normal in response to orthostatic changes, like moving from lying down to sitting or sitting to standing.

POTS criteria and prevalence

For someone without POTS, the heart rate increases around 5 to 10 beats per minute (bpm) on standing. POTS involves a heart rate increase of 30 bpm or more, or over 120 bpm, within the first 10 minutes of standing. For a child with POTS, the heart rate may increase by 40 bpm or more.

About 0.2% of the general population have POTS, including an estimated 500,000 to 1,000,000 individuals in the United States. Of those affected, 75% to 80% are women.

Migraine and POTS

Migraine and POTS share some common ground.

Of all the conditions comorbid with POTS, migraine is the most common. Studies suggest that between 41% and 96% of those with migraine also live with POTS.

POTS may be connected to migraine for a variety of reasons, including differences in three physiological functions.

These include:

• increased responsiveness and sensitivity of the central nervous system (CNS)
• dysregulation in the autonomic nervous system (ANS), which controls the fight, flight, or freeze response
• hemodynamics, or how blood flows throughout the body

Sensitization

A 2021 study concluded that there’s a significant overlap in sensitization symptoms between POTS and migraine. These include light sensitivity and allodynia, or sensitivity to touch/pain signals.

ANS dysregulation

Dysfunction of the autonomic nervous system (ANS) occurs in both migraine and POTS. People with migraine often experience autonomic symptoms as part of their migraine attacks.

These include:

• runny or congested nose
• drooping eyelids
• watery eyes
• flushing

ANS issues can lead to changes in blood flow and pain perception, including to the head.

Activation of certain brain areas relating to ANS functioning, central sensitization, and pain perception is a key factor in both conditions.

Blood flow

POTS can also involve a drop in blood pressure, which can result in less blood reaching the brain. To compensate, the ANS causes the heart to beat faster.

Understanding POTS

Understanding POTS may lead to a better understanding of migraine.

POTS symptoms

POTS is associated with a wide variety of additional symptoms, including:

• dizziness
• fainting
• tremors
• nausea
• headaches and migraine
• sweating
• pale face
• blood pooling in the limbs, or red/purple discoloration
• extreme fatigue
• brain fog

POTS triggers include:

• the menstrual cycle
• heat exposure
• level changes
• stress

Types of POTS

There are three main types of POTS.

In neuropathic POTS, damage to the nerves in the limbs means that the blood vessels cannot constrict or tighten efficiently in response to level changes.

Hyperadrenergic POTS occurs when the body releases too much of the hormone and neurotransmitter norepinephrine in response to level changes. It may be associated with faulty genes related to how norepinephrine gets reabsorbed in the brain.

Hypovolemic POTS involves blood volume that’s too low to efficiently bring blood to the brain during level changes. This causes a compensatory rise in heart rate.

Treatments for migraine

Treatments for improving ANS function and reducing central sensitization may be effective for migraine.

These include:

• Botox
• CGRP inhibitors
• antidepressants

It’s not yet known whether these treatments may be helpful for POTS as well.

Since POTS may contribute to migraine, treating the condition via lifestyle measures and medications may help those who experience both to have less frequent or painful migraine attacks.

Lifestyle considerations include:

• staying hydrated
• consuming 6 to 10 grams of salt per day
• wearing compression garments
• avoiding or moderating caffeine intake
• taking active cooling measures in hot weather
• avoiding alcohol
• minimizing stress
• moderate exercise

Prescription medications for POTS include:

• Midodrine, a blood pressure medication
• Fludrocortisone, a steroid that increases blood volume
• beta-blockers, which reduce the activity of the sympathetic nervous system
• Ivabradine, which reduces heart rate

Treatments that may worsen POTS

Some treatments for migraine may worsen POTS. For example, some types of antidepressants are not tolerated in people with POTS because serotonin and norepinephrine can both increase heart rate.

In addition, beta-blockers like propranolol are used as a treatment for both POTS and migraine. However, they aren’t a good option for people with hypovolemic or neuropathic POTS because they cause a decrease in blood pressure.

The takeaway

If you live with migraine with POTS symptoms, it’s important to seek medical care to evaluate if you have POTS. Treating POTS may help reduce the symptoms of migraine. It’s also important to be aware that some migraine treatments may not be suitable if you have POTS.

Scientific research is developing a deeper understanding of these conditions and their shared pathways and proposed treatments that may treat both simultaneously.