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Living with postural orthostatic tachycardia syndrome (POTS) can be unpredictable. You may have a period when symptoms feel relatively manageable, followed by days when standing becomes harder, your heart races more than usual, fatigue increases, or dizziness suddenly returns.
People sometimes describe these periods as a POTS flare-up, POTS attack, or POTS episode.
A flare does not necessarily mean that POTS itself has permanently worsened. Symptoms can fluctuate, and factors such as dehydration, heat, illness, prolonged standing, stress, and menstruation may make symptoms more noticeable in some people.
Understanding your individual triggers can be an important part of managing POTS.
What Is a POTS Flare-Up?
“POTS flare-up” is commonly used to describe a period when a person’s usual POTS symptoms become temporarily more frequent, intense, or difficult to manage.
POTS is an autonomic disorder characterized by orthostatic intolerance and an excessive increase in heart rate when upright. Symptoms can vary substantially from one person to another.
During a flare, someone who normally tolerates everyday activities may notice that standing, walking, showering, exercising, working, or completing routine tasks becomes more difficult.
The duration can also vary.
Some episodes may be relatively brief, while others may persist longer depending on the individual and what is contributing to the symptom change.
What Does a POTS Flare-Up Feel Like?
There is no single experience that applies to everyone.
A POTS flare may involve an increase in symptoms such as:
- Dizziness or lightheadedness
- Rapid heartbeat or palpitations
- Feeling faint or near-fainting
- Fatigue
- Weakness
- Exercise intolerance
- Shakiness or tremulousness
- Brain fog or difficulty concentrating
- Headaches
- Nausea or gastrointestinal discomfort
- Shortness of breath
- Difficulty tolerating prolonged standing
Symptoms associated with POTS typically become more noticeable while upright and may improve after sitting or lying down.
Importantly, fainting is not required to have POTS. Some people experience presyncope the sensation that they may faint without actually losing consciousness.
Why Are My POTS Symptoms Suddenly Getting Worse?
There may not always be one obvious explanation.
POTS symptoms can vary from day to day, and several factors can influence heart rate, circulation, blood volume, temperature regulation, sleep, and the body’s response to standing.
When symptoms suddenly worsen, it can therefore be useful to consider what changed before the flare began.
1. Dehydration
Adequate circulating blood volume is particularly important in POTS.
Dehydration can reduce circulating volume and may make orthostatic symptoms more difficult to tolerate.
Fluid needs are individual, particularly for people who have other heart, kidney, blood-pressure, or medical conditions. Follow the hydration and sodium recommendations given by your healthcare professional rather than making major changes independently.
2. Heat
Heat is a commonly reported POTS trigger.
When the body becomes warm, blood vessels in the skin can widen as part of normal temperature regulation. For someone already experiencing difficulty maintaining circulation while upright, heat may make symptoms more noticeable.
Potential situations include:
- Hot weather
- Hot rooms
- Hot showers
- Hot baths
- Outdoor activity during high temperatures
- Strenuous exercise in warm environments
People who notice this pattern may benefit from discussing heat-management strategies with their care team.
3. Prolonged Standing
Standing places additional demands on the cardiovascular and autonomic systems.
Because POTS is characterized by orthostatic intolerance, extended periods upright can aggravate symptoms in some patients.
Situations such as standing in line, cooking, shopping, attending events, or remaining stationary for extended periods may therefore be difficult during a flare.
4. Illness or Infection
Illness can place additional physiological stress on the body.
Fever, reduced food or fluid intake, prolonged bed rest, and dehydration during an illness may also affect POTS symptoms.
Some people additionally report POTS beginning after an infection, although POTS has multiple potential mechanisms and not everyone has the same trigger.
5. Menstruation and Hormonal Changes
Some people with POTS report changes in symptom severity during the menstrual cycle.
Research has found that lightheadedness can vary across menstrual-cycle phases in women with POTS, with symptoms reported as greatest during menstruation in one study.
Hormonal changes may influence blood volume, vascular function, and other physiological processes, although researchers are still studying exactly how these factors interact with POTS.
If symptoms repeatedly worsen around your period, tracking your cycle alongside POTS symptoms may provide useful information to discuss with your physician.
6. Stress and Strong Emotions
Stress does not mean POTS is “just anxiety.”
POTS is a physiological autonomic disorder.
However, stress activates physiological responses involving the autonomic nervous system. Strong emotions and stress may therefore make existing symptoms more noticeable in some individuals.
POTS and anxiety can also coexist, and both deserve appropriate evaluation when symptoms overlap.
7. Poor Sleep
Sleep disturbance and fatigue are common concerns among people with POTS.
A poor night’s sleep may leave someone less able to tolerate physical and cognitive demands the following day.
If persistent sleep problems accompany worsening POTS symptoms, they should be discussed with a healthcare professional rather than automatically attributed to POTS.
8. Physical Overexertion
Exercise and physical activity can be complicated in POTS.
Structured exercise may be part of an individualized management program, but suddenly exceeding your current tolerance may leave symptoms more noticeable.
The appropriate exercise program depends on individual health and functional capacity.
9. Changes in Medication
Medications can influence heart rate, blood pressure, blood volume, and autonomic symptoms.
Starting a medication, stopping one, changing a dose, or using certain over-the-counter products could potentially alter symptoms.
Do not stop prescribed medication because you suspect it is causing a flare. Discuss medication changes with the prescribing clinician.
Is a POTS Flare the Same as a POTS Attack?
Patients may use several terms, including:
- POTS flare
- POTS flare-up
- POTS attack
- POTS episode
These are generally descriptive terms rather than separate formal diagnoses.
Someone describing a “POTS attack” may mean a sudden period of racing heart, dizziness, weakness, shaking, nausea, brain fog, or near-fainting.
However, new or severe symptoms should not automatically be assumed to be POTS.
How Long Can a POTS Flare Last?
There is no universal timeline.
The course depends on the person and potentially on the trigger.
A symptom increase associated with temporary heat exposure may behave differently from worsening symptoms during an infection or a longer period of reduced activity.
Rather than focusing only on duration, consider:
- What changed before symptoms worsened?
- Are the symptoms typical for you?
- Are they becoming progressively worse?
- Are new symptoms appearing?
- Are your usual management strategies no longer helping?
Persistent or substantially different symptoms warrant medical evaluation.
What Can You Do During a POTS Flare?
Management should be individualized.
Depending on your physician’s recommendations, a POTS management plan may include strategies involving hydration, sodium intake, compression garments, physical conditioning, medication, and avoidance or modification of known triggers.
During a flare, it may also help to record:
- Heart rate
- Blood pressure, if advised
- Symptoms
- Fluid intake
- Sleep
- Menstrual-cycle timing
- Recent illnesses
- Activity level
- Heat exposure
- Medication changes
A simple symptom diary can sometimes reveal patterns that are difficult to recognize from memory alone.
When Worsening Symptoms Need Medical Attention
Not every racing heartbeat, episode of dizziness, fainting event, chest symptom, or breathing problem should be attributed to POTS.
Seek appropriate medical care for symptoms that are new, severe, rapidly worsening, or concerning particularly symptoms such as significant chest pain, severe difficulty breathing, prolonged loss of consciousness, or other signs of a medical emergency.
A clinician may need to determine whether worsening symptoms are related to POTS or another condition.
Can POTS Get Better After a Flare?
A flare does not necessarily represent permanent progression.
POTS symptoms can fluctuate.
Some patients experience periods of improvement followed by temporary worsening. Long-term outcomes also vary substantially between individuals.
If flares are becoming more frequent or severe, reviewing your treatment plan with a clinician experienced in autonomic disorders may help identify contributing factors and determine whether further evaluation is appropriate.
Frequently Asked Questions
What are common POTS triggers?
Reported factors that can worsen POTS symptoms include heat, dehydration, prolonged standing, illness, physical stress, strong emotions, and menstruation. Individual triggers vary.
What does a POTS flare-up feel like?
A flare may involve worsening dizziness, tachycardia, palpitations, weakness, fatigue, brain fog, shakiness, nausea, exercise intolerance, or near-fainting. Experiences vary between individuals.
What is a POTS attack?
“POTS attack” is an informal term people may use for a sudden increase in their usual POTS symptoms. It is not a separate formal diagnosis.
Why are my POTS symptoms getting worse?
Potential contributors include dehydration, heat, illness, hormonal changes, prolonged standing, medication changes, stress, poor sleep, and changes in activity. New or significant worsening should be medically evaluated rather than automatically attributed to POTS.
Can your period trigger a POTS flare?
Some people report worsening POTS symptoms around menstruation, and research has documented menstrual-cycle variation in orthostatic symptoms.
Can POTS flare without fainting?
Yes. Fainting is not required for POTS. Many patients experience dizziness or presyncope without losing consciousness.
Managing Recurrent POTS Flare-Ups
Repeated POTS flares can interfere with work, school, exercise, sleep, and everyday activities.
The important question is not simply how to stop one episode, but why symptoms are worsening and whether your current POTS management plan still fits your needs.
If your symptoms are becoming more frequent, more intense, or harder to manage, a clinical evaluation can help assess possible triggers, review your treatment plan, and determine whether additional testing or management changes are appropriate.
POTS.net provides specialized evaluation and care for patients experiencing POTS and other forms of autonomic dysfunction.
Schedule an appointment to discuss persistent or worsening POTS symptoms with our care team.