Understanding Migraine, POTS, and Chronic Fatigue Syndrome

We're going to explore the connection between migraines and "invisible illnesses" like Postural Orthostatic Tachycardia Syndrome (POTS) and Chronic Fatigue Syndrome (CFS).

Migraine and POTS Connection

Did you know that there’s a strong link between migraines and POTS? Studies have shown that anywhere from 41% to 96% of people with POTS also experience migraines (1). It turns out that both conditions share a common underlying mechanism involving increased sensitivity in the hypothalamus and brainstem (1).

There are several factors that can make migraines and POTS worse, such as poor sleep, lack of conditioning, increased inflammation (common in conditions like fibromyalgia and Mast Cell Activation Syndrome), certain dietary factors, and stress. It’s essential to keep these factors in mind when managing these conditions (1).


Secondary Headaches: Orthostatic Headache and Spontaneous Intracranial Hypotension (SIH)

Secondary headaches are headaches that occur as a result of underlying causes. Two such conditions that can affect someone with POTS or CFS are orthostatic headache and spontaneous intracranial hypotension (SIH).

Orthostatic headaches are still not entirely understood. But are thought to be similar to “coat hanger syndrome” where pain can be felt in the neck and shoulders. It is believed that reduced blood supply to the head and neck structures due to low blood pressure could be the culprit.

On the other hand, SIH happens when there’s low cerebrospinal fluid pressure in the head. The symptoms of SIH, like nausea, vomiting, neck pain or stiffness, hearing changes, and dizziness, can be similar to those experienced in migraines or POTS. SIH can be caused by a cerebrospinal fluid leak resulting from a small tear in the dura mater, and it’s more likely to occur in individuals with connective tissue disorders or as a result of trauma or surgery.


Differentiating Secondary Headaches

Distinguishing between orthostatic headaches and SIH can be tricky since they present similar symptoms. The key is to pay attention to how the symptoms change when you lie down versus when you stand up. In a study by Graf et al in 2018, it was found that all patients with SIH due to a spinal cerebrospinal fluid leak also met the diagnostic criteria for POTS. So, if you’re experiencing prominent orthostatic headaches, it’s worth considering evaluation for intracranial hypotension even if you’ve been diagnosed with POTS (5).

While diagnostic imaging like myelography (CT or MRI) can provide a definitive diagnosis, it’s important to note that it may miss SIH in around 20% of cases.

If you are experiencing headaches that are worse on standing and relieved when lying down, these headache types may apply to you and you should consult with your doctor to investigate it further.



Understanding the connections between migraines, POTS, and secondary headaches is key to accurate diagnosis and effective treatment. By recognising the overlapping symptoms and considering the potential impact of medications, healthcare professionals can provide comprehensive care for individuals with these conditions. If you suspect you might have any of the conditions discussed, it’s important to consult with a healthcare professional who can guide you through proper evaluation and help develop management strategies tailored to your specific needs.

  1. Cook G. Management of headache and chronic pain in POTS. Autonomic Neuroscience (2018).
  2. Riggins, N. Research Summary: Postural orthostatic tachycardia syndrome (POTS) and migraine: A narrative review. American Headache Society.
  3. Mueller, B. Postural orthostatic tachycardia syndrome and migraine: A narrative review. Headache (2022).
  4. Goldstein D. Coat Hanger Phenomenon. American Autonomic Society.
  5. Graf N. Clinical symptoms and results of autonomic function testing overlap in spontaneous intracranial hypotension and postural tachycardia syndrome: A retrospective study. Cephalalgia (2018).
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