If you have chronic migraine and feel dizzy when you stand, lightheaded while showering, or notice your heart racing during simple tasks, you're not alone. Research shows a significant connection between chronic migraine and POTS.

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What is POTS?

POTS (Postural Orthostatic Tachycardia Syndrome) is a form of dysautonomia, a condition in which the autonomic nervous system, which controls involuntary functions such as heart rate, blood pressure, and digestion, doesn't function properly.

The hallmark symptom of POTS: A heart rate increase of 30+ beats per minute within 10 minutes of standing, along with symptoms like:

• Lightheadedness or dizziness
• Rapid heartbeat and palpitations
• Fatigue and brain fog
• Nausea and GI issues
• Feeling faint or fainting
• Temperature intolerance
• Purple or mottled hands/feet
• Headaches

A formal POTS diagnosis typically requires an active stand test or tilt table test, which is usually ordered by a neurologist, cardiologist, or a dysautonomia specialist.

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How common is this overlap?

According to the American Headache Society:

• Up to 90% of POTS patients experience headache and migraine symptoms.
• Migraine is twice as common in people with POTS compared to the general population.
• POTS is more common in people with chronic or intractable migraine.

This overlap is so significant that the American Headache Society formed an Autonomic Disorders Special Interest Section to focus on improving care for patients with both conditions.

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Why do POTS and Migraine occur together?

1. Shared autonomic dysfunction

Both conditions involve an imbalance in the autonomic nervous system. The same miscommunication between brain and body can cause both types of symptoms.

POTS: The system can't properly regulate blood flow and heart rate when you change positions.

Migraine: The autonomic system misfires in response to sensory triggers. Migraine is a neurobiological disorder affecting sensory, motor, cognitive, sleep, and autonomic systems.

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2. Circulatory abnormalities

Migraine involves changes in the brain's blood flow during and between attacks.

POTS involves abnormal blood flow throughout the body. When someone with POTS stands up, the body struggles to push blood back to the heart and brain. Normal mechanisms to tighten blood vessels and maintain blood flow do not work properly. This leads to dizziness, brain fog, and visual disturbances.

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3. Inflammation and sensory hypersensitivity

Both conditions involve heightened sensitivity to light, sound, motion, heat, and physical activity. Shared mechanisms like central sensitization, where your nervous system becomes overly sensitive, and dysautonomia drive this sensitivity.

If you feel overwhelmed in crowds, heat, or busy environments, you might be experiencing this overlap. It is not just anxiety.

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What migraine-POTS overlap looks like

• Migraine attacks are triggered by standing, hot showers, or heat.
• Brain fog intensifies after physical activity.
• Your heart races when a migraine attack begins.
• You experience strong nausea during both migraines and prolonged standing.
• You feel faint or see stars before or during attacks.
• Standard migraine treatments don't fully control your symptoms.

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What does research tell us?

Current evidence does not show that treating migraine improves POTS symptoms, or vice versa. Both conditions share underlying mechanisms, such as autonomic dysfunction and central sensitization; however, there are no randomized trials demonstrating that treating one condition improves the other.

Both significantly impact quality of life and deserve comprehensive treatment. Management should be individualized, using both medication and non-medication approaches.

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Treatment approaches

Treating these interconnected conditions effectively means using a combination of approaches, including both medication and other supportive therapies. Here’s how you can manage migraine comorbid POTS.

Non-pharmacologic strategies

1. Lifestyle modifications:
   • Adequate hydration (2-3 liters daily)
   • Increased salt intake (6-10 grams daily with medical supervision)
   • Consistent sleep schedule
   • Stress management and relaxation techniques
   • Trigger identification and avoidance
2. Physical reconditioning:
   • Start with recumbent exercise (rowing, recumbent bike, swimming)
   • Gradually increase intensity
   • Physical therapy programs for POTS patients
3. Postural techniques:
   • Rise slowly from lying to sitting to standing
   • Use compression garments
   • Flex leg muscles before standing
   • Sleep with head of bed elevated
4. Environmental modifications:
   • Avoid excessive heat
   • Use stools for standing tasks
   • Manage sensory environment during flares

Pharmacologic options

For POTS:

• Midodrine, fludrocortisone, beta-blockers, ivabradine

For Migraine:

• Acute: triptans, NSAIDs, DHE, gepants
• Preventive: beta-blockers, CGRP antibodies, anticonvulsants
• Neuromodulation: eVNS, sTMS or REN devices like gammaCore, Cefaly, Nerivio etc.

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Some medications affect both conditions. Beta-blockers, for example, can reduce heart rate in POTS and prevent migraines. Others may worsen one condition while helping the other. Care from providers who understand both conditions is essential.

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If your symptoms don't fit into one box, maybe they're not meant to. Migraine and POTS often go hand-in-hand. Our providers at Neura understand this overlap, and they can help you effectively manage your symptoms. Book a visit today.

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