Postural Orthostatic Tachycardia Syndrome (POTS) caused by cervical instability
Ross Hauser, MD
In this article and explanatory video, I will discuss how cervical instability affects the function of the heart including blood pressure variations and rapid heartbeat.
One of the scariest effects of cervical instability is how it affects the heart. I’ve had patients who have made emergency room visits on numerous occasions because they thought they were having a heart attack or a heart arrhythmia. They describe their heart as fluttering or they are getting palpitations. Once they got to the emergency room, cardiac tests revealed “nothing,” they are in fact told, “everything is normal.” In a less than reassuring way some are told to relax, it must be anxiety, stress, or a panic attack and it is not their heart that should be looked at but rather their head.
Does this sound like your story? Your doctors have found nothing
This is what we hear and it may be similar to a story you have to tell.
My doctors have not found anything wrong with my heart. They tell me that they cannot give me a diagnosis for something they cannot find. On numerous occasions, I have suffered from chest pain.
I notice my chest pains sharpen when I get up from bed, chair, or any reclining or seated position. Out of nowhere, my heart rate will rapidly increase and my heart will be pounding. Sometimes my heart is pounding so hard it scares me. When I get scared I go to the emergency room. I have been to the emergency room on several occasions. Typically I will get a CAT scan of my abdomen and chest, EKG, all the blood workups, and almost as predictable as to when I know my heart will race a doctor will come to tell me that the team can not find any issues that would cause my heart to “behave” like this.
I even wore a heart monitor that showed my heart rate will race and my blood pressure will rise. Without any evidence to support that this is my heart causing this, it has been suggested to me that I have “head” problems. I need counseling to control the cause of my heart problems which must be, for lack of anything else, panic attacks. Further, I should consult with a nutritionist in case it is something in my diet.
Postural Orthostatic Tachycardia Syndrome
One of the more common problems we see as it relates to these cardiac-like problems is Postural Orthostatic Tachycardia Syndrome or POTS. POTS is the most common form of dysautonomia – problems of or dysfunction of the autonomic nervous system. It’s symptoms such as lightheadedness, palpitations, and tremulousness and is characterized by orthostatic intolerance (this is the development of many of the symptoms just described when a person stands up. These same symptoms are also relieved when a person lays down.) These symptoms can be present without with or without associated orthostatic hypotension (your blood pressure drops drastically when you stand up), and excessive autonomic system stress. One observation can be typically given in these people with these symptoms, their body is not correctly responding to a change from laying down to standing up straight. This incorrect response may be seen as:
- Excessive heart rate upon standing is the defining symptom of POTS and is characterized by a marked rise of 30 beats per minute or greater within 10 minutes of standing from supine, or greater than 120 bpm while upright.
- Tachycardia (a heart rate over 100 beats per minute) is often accompanied by a mild decrease in blood pressure. Sympathetic overactivity causes tachycardia, mild hypotension, with brain and other organ hypoperfusion (a reduction of blood flow) causing a host of other symptoms.
It is a mystery to me
Sometimes we will be contacted by someone who has done a lot of research into the origins of their problems. As may be the case for you, this aggressive need to understand what is going on stems from the fact that their doctors do not know what is wrong with them or worse, have become dismissive. Here is another story that you may find has a familiar tone to it.
It started with a concussion
I suffered a concussion, as a result, I had severe muscle spasms and tightness at the base of my skull, at the back of my neck. After physical therapy and massage, the muscles stopped spasming and the tightness went away. Then I started to have symptoms related to autonomic nervous system dysfunction. This included a high heart rate when I stood up. I was diagnosed with POTS. My neck muscles have begun spasming again and will not calm down. I am believing now that I have cervical ligament damage and cervical instability. I think it is affecting my vagus nerve and is the reason I have POTS.
My doctors don’t know. “POTS is underdiagnosed.” “POTS is understudied.”
In the sample stories that we just shared we find that people are doing a lot of research on their own trying to figure out the cause of their heart problems despite the fact that their health care professionals are telling them that they do not have a heart problem.
A July 2021 paper in the Journal of Autonomic Neuroscience: Basic & Clinical (1) comes to us from doctors at the University Hospitals Coventry & Warwickshire NHS Trust, United Kingdom of Great Britain, and Northern Ireland. The theme of this paper? “POTS is underdiagnosed.” Further, not only is POTS underdiagnosed it is understudied. Here is what these examiners noted:
“POTS is underdiagnosed with an estimated prevalence of 0.2% (Two in 1000 people). North American and Australian researchers, as well as patient groups, have called for more research into POTS. However, there has been no comprehensive appraisal of the current POTS evidence base.”
In other words, there is limited research in the published medical data and no one really knows how good that research is. It is on that research however that doctors base their treatment and diagnosis guidelines on.
There is limited research in the published medical data on POTS and no one really knows how good that research is.
To take this one step further the July 2021 special edition of the Journal of Autonomic Neuroscience (2) highlights the gaps in POTS knowledge. Specifically, the five major needs identified by doctors towards improving future care of POTS:
1) Improved understanding of POTS pathophysiology;
2) Improved data on POTS prevalence and its impact on sufferers;
3) Improved physician awareness for POTS diagnosis and access to care;
4) Improved studies on effective treatments for POTS;
5) Improved research funding for POTS. The editors add: “Indeed, there is an urgent need for well-conducted collaborative research to address the many gaps identified surrounding management of this complex condition.”
“I have severe symptoms that seem to match Dysautonomia and Postural Orthostatic Tachycardia Syndrome (POTS), but my spine specialist/neurologist and neurosurgeon are claiming not to understand my symptoms – say they are unrelated to my spine injury. Please help!”
People looking for answers.
Most people that contact our office do not contact us just for POTS or problems with a racing heart rate or dizziness and fainting sensation. Their cardio-like symptoms are often just one problem bundled among many issues that they are facing. However, we do see the patient whose symptomology is mostly focused on cardiac-like events. Let’s read some of their stories.
Panic attack or heart attack? Neither?
I have been dealing with many new, exotic, and mysterious symptoms over the last year. It all started when while walking I thought I was having a heart attack or a stroke. I went to the emergency room where all the cardio and vascular tests came back normal. Nothing was wrong with me “I only had a panic attack” brought on by anxiety. I should monitor for tachycardia symptoms moving forward.
My POTS test came back normal
My heart rate continued to bounce around. I noticed racing or variations in heart rate, especially when walking upstairs, getting up from bed or a chair, or simply turning my head one way or another. Finally, I had a POTS test. But that came back normal. So I was sent for more tests including stress tests, more lab work, more EKGs, other tests.
I am told it must be panic attacks
I experience lightheadedness, POTS symptoms, chest pain, neck pain and back pain, headaches, ear pressure, fatigue, difficulty swallowing, and more. Nothing can be pinpointed and my doctors refer back to the ER diagnosis, panic attacks brought on by anxiety.
I got diagnosed with POTS. Since then I have been bedridden. I believe I have cervical instability. I was a healthy person who had a diagnosis of primary hypertension. Now I get random bouts of dizziness and vision disturbances when standing and when I move my neck. I have now developed headaches, digestive problems, and the feeling of fullness after even eating small meals. Heart rate has been all over the place. I have had so many tests all my doctors can tell me is primary hypertension. I get medications now for that too.
No one knows
I have always struggled with neck pain and discomfort, in the last few years my pain got bad. I was told that I have pinched nerves in my neck and I started seeing a chiropractor. The chiropractor helped but only for so long. I then had these strange episodes where people though I was having a stroke, I went into a seizure-like state. I had a work up and my doctors thought I had POTS. Every time I go to the emergency room with racing heart of seizures they treat me for a migraine. But one thing that has always been consistent is the neck pain a lot of it starts in my neck and then will move to my hair down my back down my arms sometimes I have weakness in my legs and then in my arms. I was then given blood pressure medication but I felt like that really wasn’t the issue, my blood pressure does drop low when I go from standing and sitting. Because of the heart palpitations I was sent to the cardiologist. One of the nurses on one of my ER visits told me it was tachycardia.
Because of my continued neck pain I had a MRI of my neck. My doctor noticed I have a couple of herniated discs pushing against my spinal cord. I asked if this could be the problem for me, nobody really has the right answers.
Your doctors found something and it requires brain surgery
Often I will be contacted by someone who has been diagnosed with Chiari Malformation Type 1 and a list of medical “anomalies” no one can figure out. These people will tell me that they can’t hold their head up, they have upper cervical instability, they black out when they stand up and after a long series of tests they were e ultimately told they had Hyperadrenergic dysautonomia Positional orthostatic tachycardia (POTS). (This is POTS associated with higher levels of norepinephrine. Norepinephrine is a stress hormone that can show in higher levels symptoms of “roller coaster emotions from happy to sad,” panic attacks and elevated blood pressure.) In their own research they found familiar symptoms that were related to damage of the vagus nerve. They get tachycardia when they eat, sit up, get too hot. Depending on the position of their neck they have trouble breathing. But because they had a Chiari Malformation and eventually they will need brain surgery. Please see my article Chiari malformation: Non-surgical alternatives to Chiari decompression surgery
Ehlers-Danlos Syndrome? Do I have it or not?
I want to briefly discuss a very complex problem. This does not affect all POTS patients but may impact more than doctors think. Some patients do get a POTS diagnosis, especially after their doctors now suspect a diagnosis of Ehlers-Danlos Syndrome. Let’s point out that some people, specifically those with a history of joint dislocation, or double-jointed characteristics may be thought of as having Ehlers-Danlos Syndrome. Not all people with suspected POTS have Ehlers-Danlos Syndrome. The focus is on whether the hypermobile-type of Ehlers-Danlos Syndrome is causing the cervical spine to become unstable and allow for the bones of the neck to compress on the vagus nerves. This then can be seen as a possible cause of the cardiac-like problems that are characteristic of POTS.
This is something we will discuss further below. Whether cervical instability causes pressure on the vagus nerves and in fact is the underlying cause for POTS.
Here is what we hear from the people with suspected Ehlers-Danlos Syndrome.
- I have a POTS diagnosis confirmed by a tilt-table test and chronic migraine. My doctors now believe that the underlying cause of my POTS is EDS but I am waiting for genetic testing to confirm.
- I have POTS and EDS. I see an excellent hEDS doctor who has given me something new to think about. He believes my symptoms are being caused by craniocervical instability, possibly from a Cerebrospinal Fluid leak. This may be also the cause of my bad headaches and neck pain.
- My doctors are now suspecting that I have issues with my vagus nerve. I have EDS, POTS, nausea, severe leaky gut, and dizziness.
- I have had a past cervical fusion. I continue to have severe and constant back pain and POTS heart episodes. I have migraines all the time nausea, vomiting, and now endometriosis.
It’s my neck
People with and without an hEDS diagnosis can have their POTS come from neck instability. Such as the people that write us about their situation that goes something like this:
One day I woke up and I knew something was off. I went to work but I caused concern among my co-workers because I was having breathing problems and weird heart palpitations. These were things I have never felt before. When I tried to stand up it felt like I was going to pass out. This went on for months when, because of neck pain I went to a chiropractor. An x-ray showed that I had a straight neck or a “military neck.” I found that the chiropractor was giving me short-term relief from my neck pain and my problems with fainting and a racing heart. It was the chiropractor who told me about POTS.
A description of cervical scoliosis and neck pain
For the last year and a half, I have suffered from autonomic health issues specifically POTS syndrome. I also have cervical scoliosis. I have a lot of neck pain and one of the back pain specialists thought that my problems may be related to my vague nerves being compressed. I also have twitches and involuntary movements, brain fog, ear ringing.
In this video Ross Hauser, MD highlights some of the most common reasons why cervical instability or cervical dysstructure (broken neck syndrome) can be the underlying structural cause of low vagal tone and associated poor heart function, leading to POTS, or dysautonomia.
- POTS symptoms may range from mild and occasional complaints to severely incapacitating disease. Sufferers are commonly misdiagnosed as having chronic anxiety or panic disorder or chronic fatigue syndrome.
- There are a multitude of other symptoms that often accompany this syndrome including pre-syncope, syncope, dizziness, palpitations, headache, fatigue, bladder, and gastrointestinal (GI) symptoms.
Vagal tone and the ability to regulate heart function. What are we seeing in this image? A flowchart from standing up to rapid heartbeat.
The purpose of this illustration is to give a snapshot of POTS and how upper cervical instability can cause its symptoms.
- Is starts with a person standing up and their blood pressure dropping.
- As we discussed above, the body’s natural response to standing is to provide a seamless transition and an interrupted blood flow response. In a disrupted response, the blood pressure regulators and the blood flow monitors are not sending or receiving the right messages. Rapid heart rate increases to try to raise and regulate blood pressure.
- In a situation where there is cervical instability and there is compression on the vagus nerve, the messages from the vagus nerve are distorted, unreadable, or blocked. We call this phenomenon a problem of cervical dysstructure – or “broken neck syndrome.”
- Uninhibited sympathetic nerves discharging in the neck is a fancy way of saying “short-circuited” or “misfiring”.
- Because of this message misfiring or short-circuiting, the heart rate stays elevated. The cerebral blood flow is impeded.
- What happens next is symptomology:
- Panic attacks and anxiety
- Shortness of breath
- Fatigue, some to the point of exhaustion
- General body weakness
What are we seeing in this image? Cervical degenerative dysstructure (broken neck syndrome).
The progressive nature of cervical instability is demonstrated. In the normal position, the cervical spine supports the head in its natural position and the blood vessels and nerves that travel from boy to brain and back through the neck, go about their routine business.
As cervical instability develops through the breakdown of the cervical ligaments, the bones of the neck start to wander out of their natural positions. The normal neck posture is replaced by MILD loss of natural curvature. This can progress to complete loss of curvature as displayed by a MILTARY neck or straight up and down position. Finally, progression can reach the KYPHOTIC state, the curve of the neck reverses and faces the wrong way. When the neck is bent the wrong way, destructive forces are placed on the neurovascular structures including the cervical spine and vagus nerves.
Structural high blood pressure: hypertension due to atlantoaxial (C1-C2) instability
Ross Hauser, MD, and Brian Hutcheson, DC discuss the neurology behind cases of structural high blood pressure. In this video is a patient interview describing her condition and outcomes of treatment. The patient is very fit and does not meet the typical criteria for high blood pressure, poor diet, smoking, etc. Yet she had uncontrolled hypertension which can be puzzling to their doctors. By following the neurology of the symptoms, we see how upper cervical instability can impair proper vagus nerve input and restrict the blood flow that is necessary for blood pressure regulation. Our approach to cases like hers is to work on cervical curve correction as well as cervical stabilization with upper cervical Prolotherapy.
The results achieved by our patient in this video may not be typical results.
More reading and information – Can cervical spine instability cause cardiovascular-like attacks, heart palpitations, and blood pressure problems?
Cervical instability created autonomic myopathy or autonomic neuropathy, that is nerve damage that blocks or interferes with the messages sent between the brain and the heart and blood vessels, can lead to a variety of serious symptoms including postural orthostatic tachycardia syndrome (POTS).
In my companion article “Can cervical spine instability cause cardiovascular-like attacks, heart palpitations and blood pressure problems?” I describe how chest pain, a racing heartbeat, panic attacks, and anxiety may be coming from a cervical spine and neck instability pressing on the vagus nerve. It is important to realize that this may only be one possible explanation as to why seemingly healthy individuals, having been checked out by their cardiologist, have cardiovascular-type symptoms with seemingly no explanation.
I invite you to read the article in its full version via the link above.
Summary and contact us. Can we help you? How do I know if I’m a good candidate?
We hope you found this article informative and it helped answer many of the questions you may have surrounding cervical spine instability causing POTS, heart palpitations, and blood pressure problems. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.
If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff
This article discusses very similar problems that cause an elevated heart rate – Inappropriate sinus tachycardia and postural tachycardia syndrome (POTS). While they share common cardiovascular-like symptoms, there is a main difference that separates their diagnosis. POTS and its cardiovascular-type symptoms are triggered by a change in body position or orthostatic stress. Inappropriate sinus tachycardia is a condition where the heart races and there is no understandable reason for it other than it is “inappropriate.”
1 Eftekhari H, Maddock H, Pearce G, Raza S, Kavi L, Lim PB, Osman F, Hayat SA. Understanding the future research needs in Postural Orthostatic Tachycardia Syndrome (POTS): Evidence mapping the POTS adult literature. Autonomic Neuroscience. 2021 Apr 18:102808. [Google Scholar]
2 Seeley MC, Lau DH. Raising the bar in postural orthostatic tachycardia syndrome research: Evidence and challenges. Autonomic Neuroscience: Basic & Clinical. 2021 Feb 23:102790-. [Google Scholar]
This article was updated June 22, 2021