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Idiaquez J, Casar JC, Idiaquez Rios JF, Biaggioni I. Engaging patients in the management of orthostatic intolerance. Clin Auton Res 2023; 33:893-897. [PMID: 37847460 DOI: 10.1007/s10286-023-00990-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/27/2023] [Indexed: 10/18/2023]
Affiliation(s)
- Juan Idiaquez
- Departamento de Neurologia, Pontificia Universidad Catolica de Chile, Santiago de Chile, Chile
| | - Juan Carlos Casar
- Departamento de Neurologia, Pontificia Universidad Catolica de Chile, Santiago de Chile, Chile
| | - Juan Francisco Idiaquez Rios
- Division of Neurology, Department of Medicine, Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, University of Toronto, Toronto, Canada
| | - Italo Biaggioni
- Vanderbilt Autonomic Dysfunction Center and Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
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2
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Iser C, Arca K. Headache and Autonomic Dysfunction: a Review. Curr Neurol Neurosci Rep 2022; 22:625-634. [PMID: 35994191 DOI: 10.1007/s11910-022-01225-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW We explore the anatomy of the central and peripheral autonomic pathways involved in primary headache as well as the mechanisms for secondary headache associated with disorders of the autonomic nervous system. The prevalence and clinical presentation of cranial and systemic autonomic symptoms in these conditions will be discussed, with a focus on recent studies. RECENT FINDINGS Several small studies have utilized the relationship between headache and the autonomic nervous system to identify potential biomarkers to aid in diagnosis of migraine and cluster headache. Headache in postural orthostatic tachycardia syndrome (POTS) has also been further characterized, particularly in its association with orthostatic headache and spontaneous intracranial hypotension (SIH). This review examines the pathophysiology of primary and secondary headache disorders in the context of the autonomic nervous system. Mechanisms of headache associated with systemic autonomic disorders are also reviewed.
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Affiliation(s)
- Courtney Iser
- Department of Neurology, Mayo Clinic Scottsdale, Scottsdale, AZ, USA
| | - Karissa Arca
- Department of Neurology, Mayo Clinic Scottsdale, Scottsdale, AZ, USA.
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Abstract
PURPOSE OF REVIEW We define dehydration and its relationship to pain physiology including both primary and secondary headache disorders. RECENT FINDINGS Intravenous fluids administered for acute migraine attacks in an emergency department setting have not been shown to improve pain outcomes. However, increased intravascular volume before diagnostic lumbar puncture may reduce the frequency of post-lumbar puncture headache from iatrogenic spinal fluid leak. Maintenance of euhydration can help treat orthostatic and "coat-hanger" headache due to autonomic disorders. Similarly, prevention of fluid losses can mitigate secondary headaches provoked by dehydration such as cerebral venous thrombosis or pituitary apoplexy. Dehydration alone may cause headache, but oftentimes exacerbates underlying medical conditions such as primary headache disorders or other conditions dependent on fluid balance.
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Affiliation(s)
- Karissa N Arca
- Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA.
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Eagle's syndrome, elongated styloid process and new evidence for pre-manipulative precautions for potential cervical arterial dysfunction. Musculoskelet Sci Pract 2020; 50:102219. [PMID: 32891576 DOI: 10.1016/j.msksp.2020.102219] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 05/30/2020] [Accepted: 07/04/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Safety with upper cervical interventions is a frequently discussed and updated concern for physical therapists, chiropractors and osteopaths. IFOMPT developed the framework for safety assessment of the cervical spine, and this topic has been discussed in-depth with past masterclasses characterizing carotid artery dissection and cervical arterial dysfunction. Our masterclass will expand on this information with knowledge of specific anatomical anomalies found to produce Eagle's syndrome, and cause carotid artery dissection, stroke and even death. Eagle's syndrome is an underdiagnosed, multi-mechanism symptom assortment produced by provocation of the sensitive carotid space structures by styloid process anomalies. As the styloid traverses between the internal and external carotid arteries, provocation of the vessels and periarterial sympathetic nerve fibers can lead to various neural, vascular and autonomic symptoms. Eagle's syndrome commonly presents as neck, facial and jaw pain, headache and arm paresthesias; problems physical therapists frequently evaluate and treat. PURPOSE This masterclass aims to outline the safety concerns, assessment and management of patients with Eagle's syndrome and styloid anomalies. By providing evidence of this common anomaly found in almost one-third of the population, hypothesis generation and clinical reasoning with patients presenting with head and neck symptoms can improve. IMPLICATIONS Including styloid anomalies as potential hypotheses for patients with head and neck complaints can assist therapists in safe practice and expedite referral. The authors recommend updating the IFOMPT framework to incorporate Eagle's syndrome, a comprehensive autonomic assessment, and palpation of the stylohyoid complex to avoid potentially serious complications from conceivably hazardous interventions.
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Kalra DK, Raina A, Sohal S. Neurogenic Orthostatic Hypotension: State of the Art and Therapeutic Strategies. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2020; 14:1179546820953415. [PMID: 32943966 PMCID: PMC7466888 DOI: 10.1177/1179546820953415] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/31/2020] [Indexed: 11/22/2022]
Abstract
Neurogenic orthostatic hypotension (nOH) is a subtype of orthostatic hypotension in which patients have impaired regulation of standing blood pressure due to autonomic dysfunction. Several primary and secondary causes of this disease exist. Patients may present with an array of symptoms making diagnosis difficult. This review article addresses the epidemiology, pathophysiology, causes, clinical features, and management of nOH. We highlight various pharmacological and non-pharmacological approaches to treatment, and review the recent guidelines and our approach to nOH.
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Affiliation(s)
- Dinesh K Kalra
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Anvi Raina
- Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Sumit Sohal
- Division of Internal Medicine, AMITA Health Saint Francis Hospital, Evanston, IL, USA
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Kim HA, Bisdorff A, Bronstein AM, Lempert T, Rossi-Izquierdo M, Staab JP, Strupp M, Kim JS. Hemodynamic orthostatic dizziness/vertigo: Diagnostic criteria. J Vestib Res 2020; 29:45-56. [PMID: 30883381 PMCID: PMC9249281 DOI: 10.3233/ves-190655] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 02/25/2019] [Indexed: 11/15/2022]
Abstract
This paper presents the diagnostic criteria for hemodynamic orthostatic dizziness/vertigo to be included in the International Classification of Vestibular Disorders (ICVD). The aim of defining diagnostic criteria of hemodynamic orthostatic dizziness/vertigo is to help clinicians to understand the terminology related to orthostatic dizziness/vertigo and to distinguish orthostatic dizziness/vertigo due to global brain hypoperfusion from that caused by other etiologies. Diagnosis of hemodynamic orthostatic dizziness/vertigo requires: A) five or more episodes of dizziness, unsteadiness or vertigo triggered by arising or present during upright position, which subsides by sitting or lying down; B) orthostatic hypotension, postural tachycardia syndrome or syncope documented on standing or during head-up tilt test; and C) not better accounted for by another disease or disorder. Probable hemodynamic orthostatic dizziness/vertigo is defined as follows: A) five or more episodes of dizziness, unsteadiness or vertigo triggered by arising or present during upright position, which subsides by sitting or lying down; B) at least one of the following accompanying symptoms: generalized weakness/tiredness, difficulty in thinking/concentrating, blurred vision, and tachycardia/palpitations; and C) not better accounted for by another disease or disorder. These diagnostic criteria have been derived by expert consensus from an extensive review of 90 years of research on hemodynamic orthostatic dizziness/vertigo, postural hypotension or tachycardia, and autonomic dizziness. Measurements of orthostatic blood pressure and heart rate are important for the screening and documentation of orthostatic hypotension or postural tachycardia syndrome to establish the diagnosis of hemodynamic orthostatic dizziness/vertigo.
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Affiliation(s)
- Hyun Ah Kim
- Department of Neurology, Keimyung University Dongsan Hospital, Daegu, South Korea
| | - Alexandre Bisdorff
- Department of Neurology, Centre Hospitalier Emile Mayrisch, Esch-sur-Alzette, Luxembourg
| | - Adolfo M. Bronstein
- Department of Neuro-otology, Division of Brain Sciences, Imperial College London, Charing Cross Hospital Campus, London, UK
| | - Thomas Lempert
- Department of Neurology, Schlosspark-Klinik, Berlin, Germany
| | | | - Jeffrey P. Staab
- Departments of Psychiatry and Psychology and Otorhinolaryngology – Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Michael Strupp
- Department of Neurology and German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Dizziness Center, Seoul National University Bundang Hospital, Seongnam, South Korea
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Takizawa T, Shibata M, Hiraide T, Seki M, Takahashi S, Suzuki N. Possible Involvement of Hypotension in Postprandial Headache: A Case Series. Headache 2017; 57:1443-1448. [PMID: 28670690 DOI: 10.1111/head.13136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND It is commonly known that headaches are induced by intake of specific food, drink, and/or additive. In addition, some patients experience postprandial headache independent of ingestion of specific items. Currently, information on the pathophysiology underlying this particular type of headache is scarce. CASE REPORTS We report two cases in which headaches were observed after each meal. Postprandial hypotension was demonstrated in both cases. Tonometry-based continuous blood pressure measurement during head-up tilt revealed sympathetic dysfunction. In one patient, meta-iodobenzylguanidine (MIBG) myocardial scintigraphy detected cardiac sympathetic denervation, and diagnosis of pure autonomic failure was made. In both cases, treatment of postprandial hypotension was effective in relieving postprandial headache. DISCUSSION The possibility of postprandial hypotension should be explored in patients with headache that occurs after meal. To this end, tonometry-based blood pressure measurement and MIBG myocardial scintigraphy may be useful diagnostic investigations. Treating postprandial hypotension may be effective in alleviating the symptoms.
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Affiliation(s)
- Tsubasa Takizawa
- Department of Neurology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Mamoru Shibata
- Department of Neurology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Takahiro Hiraide
- Department of Neurology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Morinobu Seki
- Department of Neurology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Shinichi Takahashi
- Department of Neurology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Norihiro Suzuki
- Department of Neurology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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Gibbons CH, Schmidt P, Biaggioni I, Frazier-Mills C, Freeman R, Isaacson S, Karabin B, Kuritzky L, Lew M, Low P, Mehdirad A, Raj SR, Vernino S, Kaufmann H. The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypertension. J Neurol 2017; 264:1567-1582. [PMID: 28050656 PMCID: PMC5533816 DOI: 10.1007/s00415-016-8375-x] [Citation(s) in RCA: 249] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 12/19/2016] [Accepted: 12/20/2016] [Indexed: 02/07/2023]
Abstract
Neurogenic orthostatic hypotension (nOH) is common in patients with neurodegenerative disorders such as Parkinson’s disease, multiple system atrophy, pure autonomic failure, dementia with Lewy bodies, and peripheral neuropathies including amyloid or diabetic neuropathy. Due to the frequency of nOH in the aging population, clinicians need to be well informed about its diagnosis and management. To date, studies of nOH have used different outcome measures and various methods of diagnosis, thereby preventing the generation of evidence-based guidelines to direct clinicians towards ‘best practices’ when treating patients with nOH and associated supine hypertension. To address these issues, the American Autonomic Society and the National Parkinson Foundation initiated a project to develop a statement of recommendations beginning with a consensus panel meeting in Boston on November 7, 2015, with continued communications and contributions to the recommendations through October of 2016. This paper summarizes the panel members’ discussions held during the initial meeting along with continued deliberations among the panel members and provides essential recommendations based upon best available evidence as well as expert opinion for the (1) screening, (2) diagnosis, (3) treatment of nOH, and (4) diagnosis and treatment of associated supine hypertension.
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Affiliation(s)
| | | | | | | | - Roy Freeman
- Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Stuart Isaacson
- Parkinson's Disease and Movement Disorders Center of Boca Raton, Boca Raton, FL, USA
| | | | - Louis Kuritzky
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Mark Lew
- Keck/USC School of Medicine, Los Angeles, CA, USA
| | | | - Ali Mehdirad
- Saint Louis University Hospital, St. Louis, MO, USA
| | | | - Steven Vernino
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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Kleyman I, Weimer LH. Syncope: Case Studies. Neurol Clin 2016; 34:525-45. [PMID: 27445240 DOI: 10.1016/j.ncl.2016.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Syncope, or the sudden loss of consciousness, is a common presenting symptom for evaluation by neurologists. It is not a unique diagnosis but rather a common manifestation of disorders with diverse mechanisms. Loss of consciousness is typically preceded by a prodrome of symptoms and sometimes there is a clear trigger. This article discusses several cases that illustrate the various causes of syncope. Reflex syncope is the most common type and includes neurally mediated, vasovagal, situational, carotid sinus hypersensitivity, and atypical forms. Acute and chronic autonomic neuropathies and neurodegenerative disorders can also present with syncope.
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Affiliation(s)
- Inna Kleyman
- Department of Neurology, Columbia University College of Physicians and Surgeons, Neurological Institute of New York, 710 West 168th Street, New York, NY 10032, USA
| | - Louis H Weimer
- Department of Neurology, Columbia University College of Physicians and Surgeons, Neurological Institute of New York, 710 West 168th Street, New York, NY 10032, USA.
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Abstract
Orthostatic hypotension (OH) leads to a significant number of hospitalizations each year, and is associated with significant morbidity and mortality among affected individuals. Given the increased risk for cardiovascular events and falls, it is important to identify the underlying etiology of OH and to choose appropriate therapeutic agents. OH can be non-neurogenic or neurogenic (arising from a central or peripheral lesion). The initial evaluation includes orthostatic vital signs, complete history and a physical examination. Patients should also be evaluated for concomitant symptoms of post-prandial hypotension and supine hypertension. Non-pharmacologic interventions are the first step for treatment of OH. The appropriate selection of medications can also help with symptomatic relief. This review highlights the pathophysiology, clinical features, diagnostic work-up and treatment of patients with neurogenic OH.
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Affiliation(s)
- Pearl K Jones
- a 1 Department of Neurology, University of Texas Health Sciences Center, San Antonio, TX, USA
| | - Brett H Shaw
- b 2 Department of Cardiac Science, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Satish R Raj
- b 2 Department of Cardiac Science, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada.,c 3 Department of Medicine, Division of Clinical Pharmacology, Autonomic Dysfunction Center, Vanderbilt University, Nashville, Tennessee, USA
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Jones PK, Gibbons CH. Autonomic function testing: an important diagnostic test for patients with syncope. Pract Neurol 2015; 15:346-51. [PMID: 26109586 DOI: 10.1136/practneurol-2015-001102] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2015] [Indexed: 11/03/2022]
Abstract
Syncope is a common problem with a large differential diagnosis. The initial history and physical examination often provide initial clues; however, some cases warrant further testing to determine the underlying cause. Autonomic function testing is a safe way to evaluate patients with syncope further, and to assess their parasympathetic and sympathetic nervous systems. Autonomic testing can help to diagnose several conditions, including orthostatic hypotension, delayed orthostatic hypotension, postural tachycardia syndrome and neutrally mediated syncope. Thus, when the cause of syncope is unclear, autonomic testing can help to assess the autonomic nervous system, stratify the risk of future episodes and to guide treatment decisions.
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Affiliation(s)
- Pearl K Jones
- Department of Neurology, UT Health Science Center San Antonio, San Antonio, Texas, USA
| | - Christopher H Gibbons
- Autonomic and Peripheral Nerve Laboratory, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Martin VT, Neilson D. Joint Hypermobility and Headache: The Glue That Binds the Two Together - Part 2. Headache 2014; 54:1403-11. [DOI: 10.1111/head.12417] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2014] [Indexed: 12/31/2022]
Affiliation(s)
- Vincent T. Martin
- Department of Internal Medicine; University of Cincinnati; Cincinnati OH USA
| | - Derek Neilson
- Department of Genetics; Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
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Abstract
Syncope describes a sudden and brief transient loss of consciousness (TLOC) with postural failure due to cerebral global hypoperfusion. The term TLOC is used when the cause is either unrelated to cerebral hypoperfusion or is unknown. The most common causes of syncopal TLOC include: (1) cardiogenic syncope (cardiac arrhythmias, structural cardiac diseases, others); (2) orthostatic hypotension (due to drugs, hypovolemia, primary or secondary autonomic failure, others); (3) neurally mediated syncope (cardioinhibitory, vasodepressor, and mixed forms). Rarely neurologic disorders (such as epilepsy, transient ischemic attacks, and the subclavian steal syndrome) can lead to cerebal hypoperfusion and syncope. Nonsyncopal TLOC may be due to neurologic (epilepsy, sleep attacks, and other states with fluctuating vigilance), medical (hypoglycemia, drugs), psychiatric, or post-traumatic disorders. Basic diagnostic workup of TLOC includes a thorough history and physical examination, and a 12-lead electrocardiogram (ECG). Blood testing, electroencephalogram (EEG), magnetic resonance imaging (MRI) of the brain, echocardiography, head-up tilt test, carotid sinus massage, Holter monitoring, and loop recorders should be obtained only in specific contexts. Management strategies involve pharmacologic and nonpharmacologic interventions, and cardiac pacing.
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Affiliation(s)
- Claudio L Bassetti
- Department of Neurology, University Hospital of Bern (Inselspital), Bern, Switzerland.
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Metzler M, Duerr S, Granata R, Krismer F, Robertson D, Wenning GK. Neurogenic orthostatic hypotension: pathophysiology, evaluation, and management. J Neurol 2012. [PMID: 23180176 PMCID: PMC3764319 DOI: 10.1007/s00415-012-6736-7] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Neurogenic orthostatic hypotension is a distinctive and treatable sign of cardiovascular autonomic dysfunction. It is caused by failure of noradrenergic neurotransmission that is associated with a range of primary or secondary autonomic disorders, including pure autonomic failure, Parkinson’s disease with autonomic failure, multiple system atrophy as well as diabetic and nondiabetic autonomic neuropathies. Neurogenic orthostatic hypotension is commonly accompanied by autonomic dysregulation involving other organ systems such as the bowel and the bladder. In the present review, we provide an overview of the clinical presentation, pathophysiology, epidemiology, evaluation and management of neurogenic orthostatic hypotension focusing on neurodegenerative disorders.
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Affiliation(s)
- Manuela Metzler
- Autonomic Function Laboratory, Division of Neurobiology, Department of Neurology, Innsbruck Medical University, Anichstrasse 35, Innsbruck, Austria
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Abstract
Background Questionnaires administered to orthostatic hypotension (OH) patients reveal frequent occurrence of coat-hanger ache (CHA), but laboratory-based precipitation of CHA during head-up tilt (HUT) has not been investigated. This study compared the frequency and clinical aspects of CHA in the same group of OH patients during daily activities versus during HUT. Methods Retrospective IRB-approved review of prospectively collected data on 22 dysautonomic patients. Heart rate response to deep breathing, Valsalva manoeuver, HUT and thermoregulatory sweat test evaluated cardiovagal, adrenergic and sudomotor functions. Occurrence and clinical features of CHA during daily activities and during HUT were recorded. Data were analysed with descriptive statistics. Results All patients demonstrated severe adrenergic (OH), cardiovagal and sudomotor impairment. Of 22 patients, 13 (59%) reported CHA within 3–5 minutes of standing or after 10 minutes to 2 hours of sitting that was relieved within 5–20 minutes of recumbency. During HUT, 4 of 13 (18%) patients developed CHA. Clinical features varied. Conclusions CHA was reported by 59% of OH patients during daily activities and by only 18% during HUT. The clinical characteristics of CHA episodes displayed inter-individual and intra-individual variability. These findings militate against direct association between OH and CHA and suggest a complex pathophysiology.
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Khurana RK, Eisenberg L. Orthostatic and non-orthostatic headache in postural tachycardia syndrome. Cephalalgia 2010; 31:409-15. [PMID: 20819844 DOI: 10.1177/0333102410382792] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Orthostatic and non-orthostatic headache spectrum was prospectively studied in 24 consecutive patients with postural orthostatic tachycardia syndrome (POTS). METHODS Patients were interviewed about clinical aspects of headache and its precipitation during head-up tilt (HUT). Autonomic functions were assessed using a standard battery of tests. The relationship of orthostatic headache to cardiovascular variables was examined using unpaired two-tailed t-test. RESULTS Orthostatic headache occurred during daily activity in 14 patients (58.3%) and during HUT in 15 patients (62.5%). Age under 30 years and increasing duration of tilt were predictive for orthostatic headache. Of the 24 patients, 23 (95.8%) had non-orthostatic headache fitting the criteria of migraine or probable migraine. CONCLUSIONS Orthostatic headache affected two-thirds of POTS patients, especially those under age 30. Patients with orthostatic headache should be clinically assessed for POTS and informed of this association to reduce short-term morbidity. Migraine afflicted almost all POTS patients. This co-morbidity should be considered in management of POTS.
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Affiliation(s)
- Ramesh K Khurana
- Department of Medicine, Union Memorial Hospital, Baltimore, MD 21218, USA.
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Wieling W, Thijs RD, van Dijk N, Wilde AAM, Benditt DG, van Dijk JG. Symptoms and signs of syncope: a review of the link between physiology and clinical clues. Brain 2009; 132:2630-42. [DOI: 10.1093/brain/awp179] [Citation(s) in RCA: 172] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
Sudden falling with loss of consciousness from syncope and symptoms of orthostatic intolerance are common, dramatic clinical problems of diverse cause, but cerebral hypoperfusion is the ultimate mechanism in most. Cardiac, reflex, and orthostatic hypotension are important forms to consider. Syncope must be differentiated from seizures, psychiatric events, drop attacks, and other mimics. However, factors such as syncopal induced movements, ictal bradycardia, and insufficient clinical information can confound accurate diagnosis and hamper appropriate treatment. Progress in the diagnosis, treatment, and understanding of underlying mechanisms is continually advancing.
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Affiliation(s)
- Louis H Weimer
- The Neurological Institute of New York, New York, NY 10032, USA.
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The coat hanger sign. Mov Disord 2008. [DOI: 10.3109/9780203008454-80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] Open
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Influence of age and gender on the occurrence and presentation of reflex syncope. Clin Auton Res 2008; 18:127-33. [PMID: 18449594 DOI: 10.1007/s10286-008-0465-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2008] [Accepted: 03/25/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND The clinical history is the cornerstone of diagnosing patients with transient loss of consciousness (TLOC). Reflex syncope is the most common cause of TLOC in patients across all ages. Knowledge of the variation in incidence and clinical features of reflex syncope by age and gender provides important background information to acquire an accurate diagnosis. METHODS In a cohort of 503 patients presenting with TLOC we established a final diagnosis after systematic evaluation and two years of follow-up. The occurrence of prodromal signs, symptoms, and triggers in patients with reflex syncope was analyzed by both age (< 40 yrs, 40-59 yrs and > or = 60 years) and gender. RESULTS Reflex syncope was the most frequently obtained diagnosis (60.2%) in patients of all ages presenting with TLOC. Its occurrence was higher in patients under 40 years (73.4%), than above 60 years of age (45.3%). Pallor (79.9%), dizziness (73.4%), and diaphoresis (63.0%) were the most frequently reported prodromal signs and symptoms. Most triggers and prodromal signs and symptoms were more common in patients under 40 years of age and in women. CONCLUSIONS Reflex syncope is nearly twice as common in patients under 40 years of age than in patients aged 60 years or above. Typical signs and symptoms of reflex syncope are more common in younger patients and in women. Therefore, age and gender provide important diagnostic information and can help to decide whether additional testing is necessary.
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Affiliation(s)
- Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
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Freeman R, Kaufmann H. DISORDERS OF ORTHOSTATIC TOLERANCE-ORTHOSTATIC HYPOTENSION, POSTURAL TACHYCARDIA SYNDROME, AND SYNCOPE. Continuum (Minneap Minn) 2007. [DOI: 10.1212/01.con.0000299966.05395.6c] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Gibbons CH, Freeman R. Orthostatic dyspnea: a neglected symptom of orthostatic hypotension. Clin Auton Res 2005; 15:40-4. [PMID: 15768201 DOI: 10.1007/s10286-005-0227-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2004] [Accepted: 09/21/2004] [Indexed: 10/25/2022]
Abstract
Dyspnea is a common symptom in patients with pulmonary and cardiac disease. Orthostatic hypotension is rarely considered a cause of dyspnea. We reviewed the medical records of 651 consecutive patients referred for the evaluation of dysautonomia to investigate the prevalence of dyspnea and its association with OH and other autonomic abnormalities. Dyspnea was reported by questionnaire in 30% of patients with OH, compared to 10% of age and sex matched patients without OH (P<0.05, chi(2)). There was a trend toward earlier blood pressure falls in patients with dyspnea. During autonomic testing, 25% of patients (10 of 40) with OH who reported dyspnea on the questionnaire had shortness of breath coincident with blood pressure falls during tilt table and active standing. The time to maximal blood pressure fall was shorter in patients with OH who experienced shortness of breath during testing compared to those without dyspnea (11 minutes vs. 21 minutes, P<0.05). In this study, dyspnea was frequently associated with OH. Ventilation perfusion mismatch, due to inadequate perfusion of ventilated lung apices may be the most likely underlying cause of orthostatic dyspnea in patients with OH.
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Affiliation(s)
- Christopher H Gibbons
- Autonomic and Peripheral Nerve Laboratory, Dept. of Neurology, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Boston, MA 02215, USA
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27
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Affiliation(s)
- Louis H Weimer
- Clinical Autonomic Laboratory, Department of Neurology, Columbia University College of Physicians & Surgeons, New York, NY, USA.
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28
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Abstract
Syncope and orthostatic intolerance remain common and significant clinical problems with many undocumented, misdiagnosed, or cryptogenic cases. Careful clinical assessment and application of advancing laboratory support can further improve diagnosis and treatment. Despite the depth of existing research into these common problems, many underlying mechanisms remain unproven.
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Affiliation(s)
- Louis H Weimer
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA.
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29
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Abstract
Nonpharmacologic and pharmacologic treatment can significantly attenuate the symptoms of orthostatic hypotension. Some of the interventions that are used to treat orthostatic hypotension have been known for decades. However, several new treatment strategies have been developed in recent years. New knowledge about the pathophysiology of orthostatic syndromes has been gathered that will strongly influence the way treatments are tailored to individual patients. For example, patients with and without residual autonomic function exhibit differential responses to certain treatments. A large subgroup of patients with severe autonomic failure show a profound pressor response to water drinking. This simple effect can be exploited to treat orthostatic and postprandial hypotension in some patients. New bioengineering technologies that attempt to replicate normal baroreflex mechanisms may become available for selected patients with central autonomic dysfunction.
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Affiliation(s)
- J Jordan
- Franz-Volhard-Clinic, Haus 129, Humboldt University, Wiltbergstr. 50, 13125 Berlin, Germany.
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30
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Bleasdale-Barr KM, Mathias CJ. Neck and other muscle pains in autonomic failure: their association with orthostatic hypotension. J R Soc Med 1998; 91:355-9. [PMID: 9771493 PMCID: PMC1296807 DOI: 10.1177/014107689809100704] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Neck pain in the suboccipital and paracervical region ('coathanger' configuration) is often reported by patients with autonomic failure and orthostatic hypotension. The frequency of this pain, along with pains in the buttock and calf regions, was determined by questionnaire in two major groups with primary chronic autonomic failure--pure autonomic failure (PAF) and multiple system atrophy (MSA). Comparisons were made with Parkinson's disease, cerebellar degeneration and other disorders in which neurological symptoms overlap but in which there was neither autonomic failure nor orthostatic hypotension. Neck pain was present in 93% of patients with PAF, 51% of patients with MSA and 38-47% of the non-autonomic groups. Buttock pain was present in smaller but similar proportions (8-19%) of each group, like calf pain (23-37%). Neck pain in PAF and MSA differed from that in the other groups in being relieved by sitting or lying flat and in being associated with factors that lower blood pressure in these patients. Buttock pain was posturally related in PAF and MSA; for calf pain there was no difference between groups. Neck pain was related to the degree of orthostatic hypotension; in PAF patients, whose postural blood-pressure fall was greater than that in MSA, there was a greater frequency of neck pain.
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Affiliation(s)
- K M Bleasdale-Barr
- University Department of Clinical Neurology, National Hospital for Neurology & Neurosurgery, London, UK
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31
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Abstract
The prevalence of headache and neck pain in farmers was determined by use of a questionnaire. Information about activities which increased the symptoms and about the treatments sought was also recorded. Results showed that 77.7% of farmers experienced neck pain and 79.2% experienced headache. Driving a tractor was the activity which was most frequently described as increasing symptoms in both conditions. While driving a tractor, farmers are exposed to whole-body vibration and assume a rotated neck posture. The contribution of these factors to the development of headache and neck pain is discussed.
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Affiliation(s)
- S Scutter
- Faculty of Health and Biomedical Science, University of South Australia, Adelaide, Australia
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Low PA, Opfer-Gehrking TL, McPhee BR, Fealey RD, Benarroch EE, Willner CL, Suarez GA, Proper CJ, Felten JA, Huck CA. Prospective evaluation of clinical characteristics of orthostatic hypotension. Mayo Clin Proc 1995; 70:617-22. [PMID: 7791382 DOI: 10.4065/70.7.617] [Citation(s) in RCA: 103] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To undertake a prospective study of the clinical characteristics of orthostatic intolerant patients referred to the Mayo Autonomic Reflex Laboratory with suspected orthostatic hypotension (OH). DESIGN Autonomic function tests were performed to quantify the severity of sudomotor, adrenergic, and cardiovagal failure and generate a composite autonomic symptom score (CASS). CASS was related to a symptom score, which was derived from the frequency of orthostatic intolerance and syncope and the standing time until occurrence of symptoms. RESULTS Three groups were defined by their response to a tilt study: group I, 90 patients with symptomatic OH, mean age, 63.6 years; group II, 60 patients who had symptoms without OH, mean age, 48.9 years; and group III, 5 patients with asymptomatic OH, mean age, 68.0 years. Group I had a significantly higher CASS (P < 0.001) than did those without OH. Further analysis was done on the 90 patients in group I. The most common symptoms were lightheadedness, weakness, impaired cognition, visual blurring, tremulousness, and vertigo. The most common aggravating factors were prolonged standing, exercise, warming, and eating. Most patients (75%) could stand for less than 5 minutes before symptoms occurred. Symptoms regressed significantly with CASS but not with the tilt grade. CONCLUSION Patients with generalized autonomic failure have a recognizable pattern of symptoms and aggravating factors that relate, albeit imperfectly, to the severity of autonomic failure.
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Affiliation(s)
- P A Low
- Autonomic Reflex Laboratory, Mayo Clinic Rochester, MN 55905, USA
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