Not All POTS Is the Same: Understanding the 5 Types of Postural Orthostatic Tachycardia Syndrome

Postural Orthostatic Tachycardia Syndrome (POTS) isn’t just about a rapid heartbeat when standing—it’s a complex condition that affects multiple body systems, and it comes in several distinct subtypes. Understanding which type of POTS you have is essential to finding the right treatment.

At NeuroSport Spine and Concussion Center, we’ve helped hundreds of individuals uncover their unique POTS profile. We know that no two patients—and no two cases—are alike, which is why our care is always personalized and multidisciplinary.

🧠 The Autonomic Nervous System: POTS at Its Core

The autonomic nervous system (ANS) controls vital involuntary functions like heart rate, blood pressure, digestion, and body temperature. It includes three branches:

• Sympathetic nervous system: the “fight or flight” response, increasing alertness, heart rate, and blood pressure

• Parasympathetic nervous system: the “rest and digest” system that calms the body and supports healing

• Enteric nervous system: regulates the digestive tract

In POTS, the sympathetic system becomes overactive, keeping the body stuck in a stress-response loop. This can cause symptoms like:

• Rapid heart rate (tachycardia)

• Trouble sleeping

• Chronic fatigue

• Feeling anxious or on edge

• Poor stress tolerance

🔍 The 5 Primary Types of POTS (and Why They Matter)

Identifying the correct POTS subtype helps guide targeted treatment. Here's what we evaluate for at NeuroSport:

🔹 Neuropathic POTS – Nerve Dysfunction in the Cardiovascular System

In this subtype, nerve signals that regulate blood vessel constriction don’t work properly. This leads to blood pooling in the limbs and abdomen when standing, reducing blood flow to the brain and causing the heart to race.

Common symptoms:

• Lightheadedness or dizziness when upright

• Cold or purplish extremities

• Brain fog

• Fatigue and poor sleep

• Palpitations or fluttering heartbeat

• Exercise intolerance

• Near-fainting spells

🧪 Underlying issue: Dysfunction of the neurocardiac axis—the nerve pathway connecting the brain and heart.

🔹 Hyperadrenergic POTS – Too Much “Fight or Flight”

This form of POTS is caused by excess norepinephrine, a stress hormone that overstimulates the heart and nervous system.

Common symptoms:

• High resting heart rate (even while sitting)

• Elevated blood pressure when standing

• Anxiety, shakiness, or tremors

• Excessive sweating

At NeuroSport, we use:

• Blood tests to measure norepinephrine levels

• The cold pressor test to evaluate cardiovascular reactivity under stress

• Autonomic monitoring to assess overactivation of the sympathetic system

🔬 Learn more about hyperadrenergic POTS via Dysautonomia International

🔹 Hypovolemic POTS – Low Blood Volume, Big Consequences

This type is marked by insufficient blood volume, often due to poor sodium regulation, hormonal imbalances, or chronic dehydration.

Common symptoms:

• Dizziness, especially in heat or when dehydrated

• Extreme fatigue

• Poor tolerance to exercise or upright activity

💡 Clinical clue: These patients often respond better to fluid therapy and compression garments than to salt alone.

🧪 Diagnostics at NeuroSport include:

• Blood volume assessment

• Sodium retention testing

• Hormonal evaluation

🧵 Related read: Mayo Clinic on hypovolemia and autonomic dysfunction

🔹 Secondary POTS – When POTS Is a Symptom of Something Bigger

Secondary POTS develops as a result of another medical condition. Treating the underlying issue is key to symptom relief.

🔸 Connective Tissue Disorders (e.g., Ehlers-Danlos Syndrome, Marfan Syndrome)

• Blood vessels become overly elastic, leading to poor vascular tone

• Blood pools in the limbs and causes compensatory tachycardia

• Often includes joint hypermobility, frequent dislocations, and chronic pain

📚 More on Ehlers-Danlos Syndrome and dysautonomia

🔸 Autoimmune Conditions (e.g., Lupus, Sjögren’s, Hashimoto’s, Chronic Lyme)

• These conditions may attack the autonomic nerves or trigger inflammation

• Symptoms include palpitations, fatigue, brain fog, and dizziness

• Requires coordinated care with rheumatologists or immunologists

🔗 Visit NIH on autoimmune dysautonomia

🔸 Post-Viral Syndromes (e.g., Epstein-Barr, COVID-19)

• Inflammation or direct nerve damage from viral infections can lead to lasting autonomic dysfunction

• Common in long COVID cases with persistent fatigue and orthostatic symptoms

🔬 CDC resource on post-COVID conditions

🔸 Diabetes & Autonomic Neuropathy

• Chronic high blood sugar damages small nerves, including those regulating blood pressure and heart rate

• POTS can be an early sign of diabetic neuropathy

📖 More on diabetic autonomic neuropathy from the ADA

🔹 Mixed-Type POTS – When It’s Not Just One Cause

Many patients have overlapping features from more than one subtype. For example, someone might have both low blood volume and hyperadrenergic symptoms. That’s why a personalized, full-body evaluation is so important.

🏥 The NeuroSport POTS Evaluation Process

We don’t just treat symptoms—we dig deeper to find the root cause. Our multidisciplinary approach includes:

✅ In-depth clinical history and detailed physical exam, typically may take three hours.
✅ NASA Lean Test and real-time autonomic vital sign tracking
✅ Blood and functional lab testing as needed
✅ The Moreau POTS Protocol for structured autonomic rehab

💬 You're Not Alone—And You Deserve Answers

If you or a loved one is struggling with unexplained dizziness, fatigue, palpitations, or exercise intolerance, we’re here to help.

📍Visit us online to learn more or schedule an appointment:
🌐www.neurosportspineandconcussion.com