Nonpharmacological measures:

1. Drink 100 oz (3 L) of water daily.  You can use 1/2 pure water and 1/2 electrolyte based.  Add electrolyte powders to water, such as Liquid IV (500mg sodium), LMNT (1000 mg sodium), or NormaLyte (862mg sodium).  This will help you stay hydrated and minimize your chances of feeling lightheaded when you stand up.  

2. Drink a cool water bolus (drinking 500 mL water) within 5 minutes of feeling light-headed.  Sit down and drink the volume of water completely within a minute.  When you do this it results in a rapid and favorable cardiovascular responses including a reflex reduction in your heart rate and there is  enhanced flow of blood to your brain.  You can drink cool water bolus before an anticipated physically strenuous activity.  The effect will last up to one hour and may improve orthostatic intolerance. 

3. Keep your glass full of water at your bedside.  Prior to getting up to use the bathroom, drink the water.

4. Avoid large meals which can cause low blood pressure during digestion. It is better to eat smaller meals more often than three large meals.

5. Avoid alcohol. Alcohol and cause blood to pool in the legs which may worsen low blood pressure reactions when standing. Avoid excessive caffeine intake as it may increase urine production and reduce blood volume. 

6. Use a bedside commode or urine flask if you feel lightheaded and had falls on making the trip to the bathroom at night.

7. Use waist-high or thigh-high compression stockings producing at least 20 mm Hg to 30 mm Hg pressure.  It is also important to use abdominal binder.  Both of these should be put on before rising from bed in the morning.  These can be taken off when lying down, to avoid rise in BP when lying down.  This will avoid pooling of blood into your legs and help blood flow to the brain.  

8. Add up to 1–2 teaspoons (2.3–4.6 g) of salt per day to normal diet. Or sodium chloride tablet 1 gm by mouth three times per day.  Do not avoid salt in your diet.  This will allow more water to retain in your body and effectively increase your blood volume so that you don't get dehydrated. 

9. Make all postural changes from lying to sitting or sitting to standing slowly. 

10. Use counter maneuvers involving isometrically contracting the glutei muscles (drawing buttocks close together for 10 seconds at a time for a minute) and calf muscles (rising on tip toes) when you expect to stand in one place for some-time.  Leg crossing and bending at the waist to help return blood flow to the heart.  These will help the muscle pump blood upwards toward your heart and brain, instead of pooling in your legs.

11. Physical conditioning: rowing, recumbent stationary bike or walking in the shallow part of a swimming pool. 

12. Cardiac rehabilitation care.

13. Avoid increased core body temperature:  hot sauna, tub, or pools.  These environments can cause your blood vessels vessels to dilate and shunt blood to the periphery, depriving into brain of normal blood circulation.  

14. Elevating the head of the bed to 6 inches at night (through use of a wedge under the mattress, or placing blocks under the legs of the bed's headboard so that the head is 6 inches higher than the feet.  This will allow blood to pool in the legs, tricking the kidneys into retaining more salt and water overnight, which increases blood volume and reduces morning symptoms.  The increased blood volume from overnight fluid retention can help improve symptoms like dizziness and brain fog when you first wake up, as there is more blood available for the brain.  The key is to elevate the entire bed on a slight incline, not just use extra pillows. 

15. Avoid straining or bearing down.  Bearing down will impede blood flow back towards your heart and brain.

16. Measure blood pressure and heart rate before getting out of bed in the morning and after dinner.  Maintain a log for review. 

17. Keep a score card daily of how you feel. 1-10. 10 is worse day and 1 is best day. Can score all the numbers from 1-10. The trend of days can give us insight to how you are doing and also things that help or worsen your day to day 

Please try to follow the above non-pharmacological measure for a 2-month treatment trial.  If there is no appreciable response, I will introduce medications.  It is important to track your (a) functional capacity and (b) your top 3-5 symptoms over time to monitor treatment response.  Maintain a record of these and bring with you on your follow-up visit with me. 

Resources: 

For dysautonomia: 

Link: https://www.dysautonomiainternational.org/blog/wordpress/pleasepassthesalt/

For POTS: https://www.dysautonomiainternational.org/pdf/CHOP_Modified_Dallas_POTS_Exercise_Program.pdf

https://betterbythebeat.com/

Breathing relaxation techniques: To help reset maladapted ANS via Vagus modulation. 

2 minute breathing relaxation exercise:  https://www.youtube.com/watch?v=PzwTAf2YLh4

Diaphragmatic breathing: https://www.youtube.com/watch?v=UB3tSaiEbNY