Dizziness in CFS: What You Need to Know About NMH, POTS, and Adrenal Issues

Published: August 10, 2012

Series Parts: [ 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 ]

What's New in S.H.I.N.E. — Part 5: Hormones

Welcome to part 5 of my series reviewing and updating the core elements of the SHINE protocol for CFS and fibromyalgia.

In the first 4 parts of this series, I focused on Sleep — the "S" in SHINE. This week I begin my discussion on Hormones — the "H" in SHINE. And in particular, adrenal hormones.

Adrenal glands sit like caps on top of your kidneys. The middle part of the gland makes adrenaline, while the outer part makes cortisol, DHEA-S, aldosterone, estrogen and testosterone. About two-thirds of chronic fatigue patients appear to have underactive adrenal function. This produces symptoms such as:

  • Fatigue,
  • Recurrent infections and difficulty shaking off infections,
  • Crashing during stress,
  • Achiness,
  • Hypoglycemia (low blood sugar), with irritability when hungry. I call these "Feed Me NOW, or I'll Kill You!" attacks,
  • Low blood pressure and dizziness upon first standing.

Low blood pressure and dizziness upon standing — as well as the "crashing after exercise" exhaustion often seen in CFS patients — are CFS symptoms that are also found in two addressable disorders: POTS (Postural Orthostatic Tachycardia Syndrome) and NMH (Neurally Mediated Hypotension). Unfortunately, when conventional doctors make a diagnosis of POTS or NMH, they typically don't recognize their association with CFS. A new study shows that they should.

Association Between POTS/NMH and CFS

Researchers at Vanderbilt University School of Medicine in Tennessee studied 47 patients with POTS. Of these, 93% had severe fatigue with 64% diagnosed with CFS. The folks with CFS had far worse cases of POTS than the others. In POTS, when you stand up you have a speeding heartbeat and low blood pressure, causing symptoms like dizziness, nausea and fatigue. "Fatigue and CFS-defining symptoms are common in POTS patients," concluded the researchers in Clinical Science.

But weak adrenals isn't the only cause of POTS in CFS patients.

The area in your brain called the hypothalamus is a "circuit breaker" that controls energy for many key functions within your body, such as sleep and hormone production. It also controls blood pressure and heart rate through what is called the "Autonomic Nervous System" — a system that depends on healthy adrenal glands in order to function optimally. NMH and POTS are disorders of this autonomic function.

A diagnosis of POTS or NMH is likely to be a part of a larger CFS process if:

  • Your fatigue is severe.
  • You have insomnia.
  • You're young (5 to 30 years old).

One way to confirm this diagnosis is to undergo the "Tilt-Table Test." In this test, you are strapped to a table and held upright to see if you pass out. Though it's the best diagnostic test for POTS/NMH, in my opinion it doesn't add much. I'm comfortable addressing POTS/NMH in CFS patients on the basis of symptoms alone.

The good news is that using the SHINE protocol can not only help CFS, but it can help POTS as well. Coincidentally, the therapies for POTS/NMH, shown below, can help your CFS!

Key Therapies for POTS/NMH

  1. Increase salt and water intake. This supports the function of the adrenal glands.
  2. Get adrenal support. A great supportive supplement for the adrenals is an herbal supplement that supports adrenal function, which supplies high levels of various factors that are a must for strong adrenals, such as vitamin C, the B-vitamin pantothenate, the amino acid L-tyrosine, licorice, and adrenal gland extracts.
  3. Consider taking a stimulant such as Dexedrine, Adderal, or Ritalin. I suspect these medications are overused in hyperactive kids but underused in CFS/FM patients with POTS/NMH. (Caution: Don't use more than 30 mg a day, as these drugs can become addictive at higher doses).
  4. Consider taking ProAmitine (Midodrine). This medication can help maintain normal blood pressure.
  5. Consider taking Florinef. This prescription synthetic adrenal hormone can help in POTS.
  6. Consider taking Prozac or Zoloft. The class of antidepressant medications called SSRIs (Selective Serotonin Reuptake Inhibitors) is overused for depression (not a Prozac deficiency) but can help stabilize blood pressure. And studies show they help normalize the tilt-table test in POTS/NMH.
  7. Wear special support socks. When you stand up, blood vessels in your legs contract, shooting blood back up to your head. In POTS, that doesn't happen as efficiently. Firm compression support socks (compared to mild compression socks, for varicose veins) can help those blood vessels do their job.

To learn more about natural and medical therapies for POTS, visit the POTS Place website.


"Neurohumoral and Hemodynamic Profile in Postural Tachycardia and Chronic Fatigue Syndromes." Okamoto LE, Raj SR, Peltier AC, Gamboa A, Shibao CA, Diedrich A, Black BK, Robertson D, Biaggioni I., Clin Sci (Lond). 2011 Sep 12. [Epub ahead of print]


Jacob Teitelbaum, MD

is one of the world's leading integrative medical authorities on fibromyalgia and chronic fatigue. He is the lead author of eight research studies on their effective treatments, and has published numerous health & wellness books, including the bestseller on fibromyalgia From Fatigued to Fantastic! and The Fatigue and Fibromyalgia Solution. His newest book (June 10, 2024) is You Can Heal From Long COVID. Dr. Teitelbaum is one of the most frequently quoted fibromyalgia experts in the world and appears often as a guest on news and talk shows nationwide including Good Morning America, The Dr. Oz Show, Oprah & Friends, CNN, and Fox News Health.

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