Secondary POTS
Most patients we evaluate do not have a single cause. They have a system problem.
Secondary POTS is rarely driven by a single mechanism. Most patients present with overlapping contributors, requiring a broader clinical lens.
Secondary POTS is the most common form of postural orthostatic tachycardia syndrome we see in clinical practice. In this pattern, autonomic dysfunction is not occurring in isolation. It is being driven by an underlying condition that affects the body’s ability to regulate heart rate, blood pressure, and circulation when upright.
Instead of asking only, “Does this patient have POTS?”, we also ask, “Why does this patient have POTS?” This question changes everything for the patient. POTS is a complicated condition to treat and manage. Most people have many symptoms. In order to have the best care outcomes, each symptom needs to be measured and categorized into a section or domain. Then the “top of the cascade of symptom domains is the first target to treatment.
At NeuroSport Spine and Concussion Center, identifying that underlying driver is a critical step in building an effective care plan.
We don’t just ask,
“Does this patient have POTS?”
We ask the more important clinical question:
“Why does this patient have POTS?”
Common Causes of Secondary POTS
Secondary POTS typically arises from multiple pathways. The most common contributors we see include:
Post-Concussion Syndrome
Concussions can fail to resolve on their own. When this happens the diagnosis is Post-Concussion Syndrome or Prescient Concussion can disrupt autonomic regulation, particularly along the neurocardiac axis. New research relates this dysfunction in part to decreased blood flow within the injured parts of the brain. Perhaps, this is also why the clinical picture of concussion can be so variable, it depends on what part(s) of the brain is injured. This can lead to brain dysfunction, impaired heart rate control, exercise intolerance, and persistent dysautonomia.
Autoimmune and Post-Viral Conditions
An over reaction or inappropriate immune system activation may interfere with autonomic signaling leading to dysautonomia and POTS. Many patients report onset following an immunization and/or illnesses, including viral infections. Autoimmune dysfunction (dysautonomia) is though to occur because the bodies own antibodies may target and damage the autonomic nervous system(ANS) or ANS receptors that regulate blood vessel constriction, blood pressure pressure feedback and heart rate. This immune dysregulation often disrupts vascular tone, causing blood pooling in the legs upon standing, forcing the heart to race to compensate by increases the pulse. We have seen this version of POTS in people, especially adolescents, following immunizations. Other autoimmune disorders such as long COVID, Lupus, Lyme’s disease, severe mononucleosis also may be connectors to POTS.
Connective Tissue Disorders
Connective tissue disorders are commonly encountered in POTS patients. Connective tissue disorders (Hypermobility Spectrum Disorders (HSD), Ehlers-Danlos Conditions such as hypermobile Ehlers-Danlos syndrome can adversely affect the blood vessel wall firmness or structure leading to a decrease in vascular integrity. This then leads to poor blood vessel wall support and increased orthostatic stress from blood pooling within the vessels.
Neuropathic Dysfunction
Damage or dysfunction of small nerve fibers can impair vascular constriction, allowing blood to pool in the extremities when standing. We do not classify POTS from car crashes or concussion as Neuropathic POTS because this version of POTS is associated with small nerve fiber dysfunction, not head injury.
Hypovolemia
Reduced blood volume can contribute to exaggerated heart rate responses as the body attempts to maintain cerebral perfusion.
Deconditioning
Periods of inactivity, illness, or injury can reduce autonomic tolerance and worsen orthostatic symptoms.t
Clinical Presentation
Patients with secondary POTS meet standard criteria for orthostatic intolerance, but their symptoms are part of a broader clinical picture.
Secondary POTS (Postural Orthostatic Tachycardia Syndrome) occurs when symptoms of orthostatic intolerance (rapid heart rate, lightheadedness) arise because of another underlying medical condition. Common causes include autoimmune disorders (lupus, Sjögren’s), immunization reactions, connective tissue disorders (Hypermobility Spectrum Disorders (HSD), Ehlers-Danlos Syndrome (EDS), diabetes mellitus, and infections. We also see patients who develop POTS after neurosurgical procedures. Treating the primary condition is key to managing symptoms. Patients with secondary POTS often present with a combination of:
Rapid heart rate with standing
Lightheadedness or dizziness
Fatigue and reduced endurance
Brain fog or cognitive slowing
Exercise intolerance
Headache or pressure
Temperature dysregulation
Gastrointestinal symptoms
A key feature is that symptoms often develop in the context of another condition, rather than appearing in isolation.
Why Secondary POTS Is Often Missed
This is where many patients get misdiagnosed, dismissed, or misunderstood. The clinical focus is often placed on symptoms alone. The evaluation and management of POTS is complicated, takes time, and careful consideration by the clinician. Often the patient hears:
“It’s anxiety”
“Your heart is fine”
“You just need to condition more”
“You need to better understand why you are doing this to yourself.”
Dysautonomia International reports 60% of dysautonomia/POTS patients are misdiagnoses as having a psychogenic disorder, when the actual cause is physiologically explainable. What gets missed is the identification of the underlying driver. When the underlying driver is missed, treatment becomes inconsistent, incomplete, and often ineffective.
The NeuroSport Approach to Evaluating Patients
At NeuroSport, evaluation is structured to identify both:
The presence of autonomic dysfunction
The underlying contributors driving it
Assessments include:
Detailed clinical history with a focus on the pattern or onset
Orthostatic testing; including the NASA Lean Test, Active Stand Test or other structured orthostatic testing
Measuring heart rate and blood pressure response to positional changes
Symptom reproduction during testing
Screening for concussion-related dysfunction and dysautonomia
Evaluation of ocular dysfunctions secondary to dysautonomia
Evaluation for connective tissue features
Identification of post-viral or immune triggers
Cold Pressor Test when indicated
Review of prior labs and imaging
The goal is not just diagnosis.
The goal is identifying the cause of the system breakdown.
It takes a thoughtful and thorough evaluation to get the right diagnosis. Typical NeuroSport POTS intake examinations may take three or more hours to sort all this complicated presentation out!
NeuroSport Treatment and Management Principles
Standard exercise or generalized care often fails in secondary POTS because the underlying driver has not been addressed.
Management of secondary POTS requires a dual approach:
1. Stabilize the Autonomic System
Hydration and electrolyte strategies
Gradual autonomic rehabilitation
Controlled progression of activity
Sleep optimization
Trigger identification
Management of ocular dysfunction
2. Address the Underlying Driver
Concussion-focused care when present
Immune or inflammatory considerations
Structural and cervical contributions
Vascular and volume-related factors
At NeuroSport, the Moreau POTS Protocol (MPP) is used when appropriate to guide progressive autonomic rehabilitation with real-time physiologic monitoring.
The NeuroSport Perspective
Secondary POTS is not a single diagnosis. It is a pattern of dysfunction with a cause or causes. This is why protocols must be individualized, and progression carefully managed.
Most patients we evaluate fall into this secondary POTS category, often with overlapping mechanisms, including:
Post-concussion + autonomic dysfunction
Autoimmune + hypovolemic patterns
Neuropathic + hyperadrenergic features
That is why care must be individualized and progression carefully managed.
Concerned About Secondary POTS?
If your symptoms began after injury, illness, or another medical condition and include dizziness, rapid heart rate, fatigue, or exercise intolerance, a structured autonomic evaluation at NeuroSport can help identify the underlying driver and guide targeted care.