POTS Treatment in Lyme Disease: What Helps?
Dizziness, rapid heart rate, and fatigue may reflect POTS
Treatment usually combines fluids, salt, compression, and conditioning
Medications may help selected patients
Patients with Lyme disease often ask whether treatment is available for the dizziness, rapid heart rate, fatigue, and exercise intolerance that can persist even after the infection itself has improved. These symptoms may reflect postural orthostatic tachycardia syndrome (POTS) or a broader form of autonomic dysfunction.
Although there is no single treatment that works for everyone, lifestyle measures and carefully selected medications may improve symptoms and quality of life for many patients.
In a systematic review published online in 2025 in Clinical Autonomic Research, Schiweck and colleagues analyzed 45 studies evaluating therapies for POTS, providing one of the most comprehensive summaries of current treatment options.
What Is POTS?
POTS is generally defined by symptoms of orthostatic intolerance and a sustained increase in heart rate of at least 30 beats per minute in adults or 40 beats per minute in adolescents after standing, without a significant drop in blood pressure known as orthostatic hypotension.
Patients with Lyme disease may also experience broader forms of autonomic dysfunction and orthostatic intolerance that do not meet the formal diagnostic criteria for POTS but can produce many of the same symptoms.
Common symptoms include:
- Rapid heart rate or palpitations
- Dizziness or lightheadedness when standing
- Near-fainting or fainting
- Brain fog
- Fatigue
- Exercise intolerance
- Blurred vision
- Nausea
- Headaches or migraines
- Sleep disturbances
- Abdominal discomfort and other gastrointestinal symptoms
Many patients report that symptoms worsen when standing and improve after sitting or lying down.
Why Does POTS Occur?
POTS is considered a heterogeneous disorder with several proposed mechanisms. Researchers have described excessive sympathetic activation, impaired peripheral autonomic function, low blood volume, vascular abnormalities, and immune dysregulation as potential contributors.
Autonomic dysfunction has also been described in several neurologic disorders, including multiple sclerosis, movement disorders, dementia, cerebrovascular disease, and peripheral neuropathies. This suggests that dysfunction of the autonomic nervous system can occur in a variety of medical conditions.
In Lyme disease, autonomic symptoms may reflect nervous system involvement, immune activation, or other mechanisms that are still being investigated.
Non-Pharmacologic POTS Treatment
POTS treatment usually begins with conservative measures. The systematic review found evidence supporting several non-pharmacologic strategies that may reduce symptoms in selected patients.
- Increase fluid intake.
- Increase dietary salt when appropriate and medically safe.
- Wear compression stockings or abdominal compression garments to reduce venous pooling.
- Begin a gradual, individualized exercise program that emphasizes recumbent or semi-recumbent exercise before progressing to upright activities.
- Avoid prolonged standing and recognize situations that commonly trigger symptoms.
These measures are often recommended before medication is prescribed and frequently remain part of long-term management when medications are added.
Medications Used to Treat POTS
If lifestyle measures alone are not sufficient, medications may be added based on an individual’s symptoms, blood pressure, heart rate, and coexisting medical conditions. No single medication is effective for every patient, and treatment often requires careful adjustment over time.
The systematic review identified several medications that demonstrated potential benefits in selected patients with POTS.
- Beta-blockers may reduce excessive heart rate and improve palpitations.
- Midodrine, an alpha-agonist, can support standing blood pressure by reducing venous pooling.
- Fludrocortisone, a mineralocorticoid, may increase blood volume through sodium and water retention.
- Pyridostigmine may improve autonomic nervous system function in selected patients.
- Ivabradine (Corlanor) lowers heart rate without significantly lowering blood pressure and may be helpful for carefully selected patients.
Ivabradine is FDA approved for certain patients with heart failure but is not FDA approved specifically for POTS. According to the systematic review, ivabradine and beta-blockers were supported by several studies, while more limited evidence suggested potential benefits from midodrine and pyridostigmine in selected patients.
POTS Treatment Should Be Individualized
Patients with Lyme disease frequently present with overlapping symptoms, including fatigue, dizziness, exercise intolerance, cognitive dysfunction, gastrointestinal complaints, and blood pressure abnormalities. Some meet the formal diagnostic criteria for POTS, while others have broader autonomic dysfunction or orthostatic intolerance.
Recognizing this distinction is important because treatment should be based on the patient’s overall clinical presentation rather than heart rate alone.
When Lyme disease or an associated co-infection is present, it should also be evaluated and managed appropriately. Supportive treatment directed at autonomic dysfunction may still be required.
Frequently Asked Questions
How is POTS diagnosed?
POTS is diagnosed by evaluating symptoms and measuring heart rate and blood pressure after a person moves from lying down to standing. A standing test or tilt-table test may be used. Other conditions that can produce similar symptoms should also be considered.
Can Lyme disease be associated with POTS?
POTS and other forms of autonomic dysfunction have been reported following Lyme disease. However, not every patient with Lyme disease develops POTS, and not every patient with POTS has Lyme disease.
What treatments help POTS symptoms?
Treatment commonly begins with increased fluids, salt when medically appropriate, compression garments, and gradual individualized conditioning. Medications such as beta-blockers, midodrine, fludrocortisone, pyridostigmine, or ivabradine may be considered for selected patients.
Can someone have POTS symptoms with a negative tilt-table test?
Yes. Some patients have orthostatic intolerance or broader autonomic dysfunction without meeting the formal criteria for POTS during testing. Symptoms can also fluctuate, so the clinical history remains important.
Clinical Takeaway
In my practice, autonomic dysfunction is one of the more disabling neurologic complications affecting patients with Lyme disease. Many patients have difficulty standing for prolonged periods, exercising, concentrating, or completing routine daily activities.
Successful treatment often requires combining hydration, salt supplementation when appropriate, compression garments, gradual conditioning, and carefully selected medications. Improvement is frequently gradual and requires periodic reassessment as symptoms evolve.
Not every patient with orthostatic symptoms has classic POTS, and not every patient with POTS has Lyme disease. Careful evaluation can help identify contributing factors and guide individualized treatment.
Recognizing autonomic dysfunction and tailoring treatment to the individual patient may substantially improve function and quality of life.
Related Articles
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Could POTS impair cognitive function when standing?
What exactly is postural orthostatic tachycardia syndrome?
References
- Schiweck N, Langer K, Maier A, et al. Systematic literature review: treatment of postural orthostatic tachycardia syndrome (POTS). Clin Auton Res. 2026;36(1):3-16.
- Tahir F, Bin Arif T, Majid Z, Ahmed J, Khalid M. Ivabradine in Postural Orthostatic Tachycardia Syndrome: A Review of the Literature. Cureus. 2020;12(4):e7868.
- Xiong L, Leung TWH. Autonomic dysfunction in neurological disorders. Aging (Albany NY). 2019;11(7):1903-1904.
- Wells R, Spurrier AJ, Linz D, et al. Postural tachycardia syndrome: current perspectives. Vasc Health Risk Manag. 2018;14:1-11.
- Kanjwal K, Karabin B, Kanjwal Y, Grubb BP. Postural orthostatic tachycardia syndrome following Lyme disease. Cardiol J. 2011;18(1):63-66.
Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.
Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention
Do we see resolution of POTS with treatment of Lyme disease or is this damage done?
I often see marked improvements in my practice if the cause is a tick borne illness.
I often see marked improvements in my practice if the cause is a tick borne illness.
Yes. I have a patient with POTS who also has lyles disease which I am treating manually (MLD) to the cervical and occipital lymph vessels which accelerates cerebral spinal fluid exit into nasal mucosa and spinal meninges
Dear Dr. Cameron,
The first diagnosis I received in regards to my maladies was Hashimoto’s Thyroiditis, 1986. Followed by Endometriosis, 2003, CFS 2006, Adnomyosis 2006 (full hysterectomy 06/2006) never recovered. 2012 hospitalized for 10 days, 2.3 Hemoglobin. Received 50 Blood Transfusions, still no diagnosis. 17 Root Canals, all failed. Tonsillectomy 2013. Finally 08/2013 tested for Bb, Western Blot ~ Positive for Lyme Disease. 2013 w/Dr. R. Stricker testing & treatment for Bb pos, Babesia pos, Ehrlichia pos. via IGeneX. Presently still displaying symptoms. Testing w/Internist via Quest Diagnostics. New results as follows: LYME AB SCREEN
View trends Index value >0.90. My Question: Do I or should I request additional testing?? Per Website: If Lyme Disease Antibody Screen is ≥0.90, then Lyme Disease Antibodies (IgG, IgM), Immunoblot will be performed at an additional charge (CPT code(s): 86617 x2). I do not believe an Immunoblot was ordered or performed. Your thoughts? Which direction should I proceed? Should tests be performed through IGeneX? My state is governed by IDSA Rules and Regulations. Thank you, Dr. Cameron, you are a blessing and a hero to so many.
Do we see resolution of POTS with treatment of Lyme disease or is this damage done?
My 12 year old has all of these symptoms but was treated for Lyme disease 3 years ago. Could it be this? Her symptoms are palpitations, dyspnea, chest discomfort, lightheadedness, nausea, blurred vision, chronic fatigue, sleeping abnormalities, migraines, hypermobile joints, abdominal pain. And she’s also getting muscle twitches. Her doctors brush off the Lyme because she was treated but all of her testing is coming back good.
I have patients in my practice who have benefited from retreatment for a tick borne illness. I have had these patients be sure there is not another illness.
I have patients in my practice who are doing well after re-treatment for a tick borne infection despite being previously treated. They often have a number of what initially was thought to be unrelated conditions. Of course, they need to be evaluated for other illnesses.
I have hereditary alpha tryptasemia, and my son was just diagnosed with lyme/ co infection of ebv with a wonderful functional med dr you work with ( Dr G Brown. )I have noted cyanosis on my sons legs , along with the brain fog and fatigue , bp at 90/50 .Would like to take him for valsalva /qsart/ tilt but the local hospital here won’t even recognize the lyme . Do you do autonomic testing or know a Lyme friendly autonomic specialist. I’m not sure where the appropriate place to go for lyme related dysautonomia eval would be . Happy to come to NY. …
I have young patients with tick borne illnesses whose autonomic illness can be quite ill with autonomic issues. Some of them get better with treatment with antibiotics. I have had to treat some of them for autonomic issues at the same time. I do not do a tilt table in my office.
I was recently diagnosed with POTS after being hospitalized being tachicardic (heart rates of 150-160 dropping to 60s/70s in seconds). I have a family cardiac history of my father passing from a heart attack at 53 and mother had a heart attack and triple bipass. I have previous diagnosis of Lyme, babesia, parasites, ebv, bartonella, low hormone levels, heavy metal toxicity and mold. Also previous kidney infection and current bilateral stones. I started a beta blocker metoprolol and had horrible side effects though it worked for improving my heart rate I recently had to stop taking. Do you have any suggestions for medication that has worked well for Lyme patients with pots?
I have Lyme disease patients who have POTS. I do not have any new medications. I have patients whose response to medications for POTS improved when their Lyme disease was treated.
I have chronic Lyme, dysautonomia, lupus, gastroparesis and biliary dyskinesia…I have been living with this a very long time…I have had five bullseye rashes in twenty years time and recently bitten again last summer and symptoms got extremely worse..I’m trying to take supplements because I can’t afford a LLMD right now
What came first? Did Lyme disease cause your dysautonomia?
My son has POTS. EDS. MCAS I have people argue with me that it’s not that it’s JUST LYMES. I beg to differ. Your thoughts??
I have patients who fit more than one diagnostic criteria. They typically see more than one specialists during their evaluation and treatment.