The 3 Types of POTS: Neuropathic, Hyperadrenergic and Hypovolemic

If you've been diagnosed with POTS, you may have been treated as though every POTS patient is the same: the same medications, the same exercise protocol and the same advice. If that approach hasn't worked for you, there's a reason. POTS can come about in different ways, and while our team cares more about identifying mechanisms than handing out labels, the 3 classic subtypes are worth understanding because they show why no 2 cases should be treated alike.

What All Types of POTS Have in Common

In every type of POTS, the body is doing the same thing: when you stand, your blood pressure wants to drop, and you've got enough in the tank to signal the heart to save the day. The heart speeds up, 30 or more beats per minute in adults and 40 or more in teens, and pulls blood pressure back to normal. Snap a picture of that moment and you see a normal blood pressure with a high heart rate, which is POTS in a nutshell (Raj, 2013).

A normal blood pressure doesn't guarantee normal blood flow to the brain, though. From the heart to the head, blood has to travel uphill against resistance, and even with a normal arm cuff reading, the brain can come up short. The difference between the types is why blood pressure is struggling to begin with, and that why decides what will help.

Neuropathic HyperPOTS Hypovolemic

Neuropathic: the nerves that tighten the veins of the belly and legs are partly lost, so blood pools low, less returns to the heart, and the heart speeds up to make up for it.

A simplified picture: most people have features of more than one type.

Type 1: Neuropathic POTS

In neuropathic POTS, the nerves that control blood vessel tension aren't doing their job. To keep pressure up when you stand, your vessels need to hold tension, like a thumb over a garden hose that makes the water shoot higher. In neuropathic POTS the grip isn't strong enough, the vessels can't hold that tension, pressure starts to drop, and the heart steps in.

A 2000 study measured norepinephrine, the chemical sympathetic nerves release to tighten vessels, coming out of the arms and the legs. In people with POTS, the arms responded normally, while the legs released far less, and the authors concluded that neuropathic POTS comes from partial loss of the sympathetic nerves, especially in the legs (Jacob, 2000). Blood then pools in the lower body, less returns to the heart, and the heart rate climbs. Signs of small fiber neuropathy can show up in this type (Vernino, 2021), and so do the purple, heavy legs of blood pooling.

Type 2: Hyperadrenergic POTS

This is the subtype that tends to produce the most intense symptoms and the one most likely to be mistaken for an anxiety disorder. To make the heart beat faster, your body releases norepinephrine, the chemical messenger of the sympathetic nervous system. When blood pressure keeps wanting to drop, that feedback loop stays wide open and norepinephrine keeps flooding the system. In hyperadrenergic POTS, standing norepinephrine often runs above 600 pg/mL (Raj, 2013).

High norepinephrine produces symptoms of its own: feeling hot and sweaty, palpitations, a wired, shaky feeling and rising anxiety, along with tremor, migraine and chest pain that can feel like angina (Vernino, 2021). They're the predictable result of a nervous system working flat out to keep you upright, which is what you'd expect to feel when your brain senses it's getting choked of blood. In most people the high norepinephrine follows another problem, such as partial nerve loss or low blood volume, and only a small group seems to start with excess sympathetic drive, often with standing levels above 1,000 pg/mL (Raj, 2013).

Type 3: Hypovolemic POTS

In hypovolemic POTS, blood volume is lower than expected for your size. In one study, people with POTS were about 690 mL short of their predicted blood volume against about 230 mL in healthy controls, and their kidney hormones that should defend volume didn't rise to meet the shortfall (Raj, 2005). Blood volume is hard to measure precisely, which makes this type harder to pin down than the others.

Our team looks at it as an allocation question as much as an amount: is the brain controlling where blood goes in a dynamic way, or is it pooling in some places and coming up short in others? That's why adding salt and water helps some people for a while and then stalls, and why so many end up dumping the extra fluid.

HyperPOTS vs POTS: What's the Difference?

HyperPOTS is short for hyperadrenergic POTS, so it's one type of POTS rather than a separate condition. Everyone with POTS has the 30-beat heart rate rise on standing; hyperPOTS adds high standing norepinephrine, sometimes a rise in blood pressure when you stand, and the sweaty, shaky, wired symptoms above. Because the high norepinephrine is usually a response to something else, the more useful question is what's driving it, which is the focus of our hyperadrenergic POTS guide.

What Are the 4 Types of POTS?

Some lists add a 4th type, and which one depends on the source. The most common addition is an autoimmune or immune-related type: POTS can start after a viral illness, and about 20% of people with POTS report an autoimmune condition such as Hashimoto's thyroiditis, rheumatoid arthritis or Sjögren's syndrome (Vernino, 2021). Others add deconditioning, since a smaller heart and long bed rest make standing harder on their own.

The 2019 NIH expert consensus put the bigger point plainly: these mechanisms are neither fully inclusive nor completely exclusive, many patients show features of more than one, and so far there's no data showing that prognosis or response to treatment differs by subtype (Vernino, 2021). That's why our team doesn't stop at the label and measures the mechanism underneath it.

When It Isn't POTS: Fainting and Low Brain Blood Flow

POTS is one branch of a bigger family called orthostatic intolerance, the umbrella for feeling bad when you're upright. If your blood pressure drops when you stand, that's orthostatic hypotension, and fainting usually means the pressure fell far enough to cut blood flow to the brain, which points away from POTS, where the heart is holding pressure up. Then there are people with normal blood pressure and a heart rate rise under 30 who still lose blood flow to the brain upright, which shows up as hypocapnic cerebral hypoperfusion when CO2 runs low, or orthostatic cerebral hypoperfusion syndrome when it doesn't. In a 2024 study, people with low brain blood flow and no POTS-level heart rate lost about as much blood flow to the brain upright as people with POTS (Novak, 2024).

How to Find Your Type of POTS

A standard tilt test confirms the heart rate rise, and it can't tell the types apart on its own. Clinics use pieces like standing norepinephrine, skin biopsies or sweat testing for small fiber neuropathy, and occasionally blood volume studies, and even then, a simple test to sort each patient into a type has remained elusive (Raj, 2013).

Our testing goes after the mechanism instead. During the tilt, we measure blood flow to the brain with transcranial Doppler, the CO2 in each breath, heart rate and blood pressure together, and we watch the order things happen in as you go upright. A hands-on bedside exam adds the nervous system side: eye movements, balance, body sense and the reflexes that steer blood. That tells us whether your racing heart is making up for pooling, for low volume or for a brain that isn't directing its own blood flow well, and that's where treatment starts.

Types of POTS: FAQ

Keep Reading

• Hyperadrenergic POTS: symptoms, causes and treatment
• Blood pooling in POTS: why it happens in legs and arms
• POTS and water retention: why you keep dumping fluid
• Orthostatic intolerance: what it is and why it happens
• How we evaluate and treat POTS

Dr. Keiser is a board-certified chiropractic neurologist (DC, DACNB, FABBIR), not a medical doctor (MD/DO). This content is for educational purposes and does not constitute medical advice. It is not a substitute for professional medical evaluation, diagnosis, or treatment. Always consult a qualified healthcare provider about your specific situation.

← Back to Blog