Pots and Brain Fog
Guideline: Heart Rhythm Society POTS consensus 2015; Dysautonomia International
What Is Pots-Related Brain Fog?
POTS is not anxiety. A 2020 JAHA study confirmed measurable cerebral blood flow deficits during standing that directly correlate with brain fog severity. 60% of POTS patients report salt loading improves their cognitive symptoms. First-line treatment is FREE: salt, water, compression, and exercise.
What to Do This Week
Seven actionable steps you can start today — free, evidence-based, and designed for when you're foggy.
Body
Sit or lie down if dizzy — don't push through. Counter-maneuvers: cross legs and squeeze thighs when standing. Contract calf muscles repeatedly. These physically pump blood back to your brain.
Food
Drink a glass of salty water right now (½ tsp salt in 500ml). Eat something salty: olives, salted nuts, pickle, miso soup. Small frequent meals — don't fast.
Water
500ml water with ½ tsp salt, 4-6 times daily. Start your day with salt water before getting out of bed. Dehydration is POTS's worst enemy. ⚠️ NOT for heart failure, uncontrolled hypertension, or kidney disease without medical clearance.
Environment
Stand up slowly. Sit on the edge of the bed for 30 seconds before standing. Cross legs when standing still. Avoid hot showers/baths (heat dilates blood vessels, worsening symptoms). Keep room cool.
Connection
POTS communities are incredibly supportive and knowledgeable: Dysautonomia International, POTS UK, Standing Up to POTS. People there have lived through exactly what you're experiencing.
Tracking
NASA Lean Test at home (free): lie flat 5 min, stand against wall 10 min. Record heart rate at 1, 3, 5, 10 min. HR increase >30 bpm = take this data to your GP. Repeat weekly to track progress.
Avoid
Don't fast. Don't do hot yoga. Don't stand still for long periods. Don't dehydrate. Don't let doctors dismiss your symptoms because your blood pressure is 'normal' — POTS is a heart RATE problem, not a blood pressure problem.
What to Eat: The Steady Meals — No Fasting Approach
For conditions where blood sugar stability or regular energy intake is critical. Anti-crash eating.
Sample Day
- breakfast: Eggs + avocado + sourdough toast (within 1 hour of waking)
- midMorning: Greek yogurt + handful nuts
- lunch: Chicken + sweet potato + mixed salad + olive oil
- afternoon: Apple + cheese or nut butter
- dinner: Fish + rice + roasted vegetables
- preBed: Small handful almonds + banana (if needed)
For Pots: POTS-specific: smaller, more frequent meals (large meals pool blood in gut). Increase salt to 10-12g/day (unless heart failure/CKD — check with doctor). 2-3L fluid/day. DIY electrolyte: ½ tsp salt + squeeze lemon in 500ml water. Avoid alcohol completely during stabilization.
This is about STABILITY, not restriction. Eat enough. If you have POTS, ME/CFS, or migraine, fasting is harmful, not healing. Ignore intermittent fasting trends if you crash.
When to Seek Urgent Help
STOP — Seek urgent medical evaluation if: sudden onset of cognitive symptoms (hours/days), new focal neurological symptoms (weakness, numbness, vision or speech changes), seizures, fever with confusion, or rapidly progressive decline. These may indicate a medical emergency requiring immediate care, not lifestyle modification.
Tests and Investigations
Autonomic Testing
- NASA Lean Test (home screening)
- Tilt Table Test (confirmatory — request transcranial doppler if available)
- Autoimmune panel (autoimmune POTS is treatable)
- Blood panel: ferritin, B12, vitamin D, cortisol, TSH, ANA
Evidence-Based Lifestyle Changes
Salt + Fluid Loading
3-10g sodium daily (start at 3g, increase gradually as tolerated) + 2-3 liters fluid daily. Electrolyte drinks, salt tablets, or salt capsules with meals. Front-load morning hydration.
Evidence: Strong — consensus guideline. Ross et al., Clin Auton Res, 2013: 60% improved brain fog with salt, 66% with fluids, 77% with IV saline.
Compression Garments
Waist-high compression stockings (30-40mmHg) OR abdominal binder during waking hours. Knee-high stockings are less effective — the abdomen is where most blood pools.
Evidence: Strong — Bourne et al., JACC, 2021: compression reduced orthostatic tachycardia and symptoms
Recumbent Exercise Program (Levine/CHOP Protocol)
START recumbent (swimming, rowing machine, recumbent bike) 20min 3x/week. Add 5min/week. After 2-3 months, gradually add upright exercise. NEVER start with standing exercise.
Evidence: Strong — Fu et al., JACC, 2010: exercise training more effective than beta-blockers for POTS
Counter-Maneuvers
When symptomatic: cross legs and squeeze thighs, squat, tense abdominal muscles, elevate legs. Avoid prolonged standing and hot environments.
Evidence: Strong — consensus guideline
Holistic Support
Compression garments
Strong — medical-grade compression (waist-high, 30-40mmHg) is first-line POTS treatment. Prevents blood pooling in legs/abdomen.
Waist-high compression stockings or abdominal binder. Put on BEFORE getting out of bed. Medical grade > fashion grade.
Reclined exercise (starting position)
Strong — Levine Protocol (modified Dallas program). Recumbent bike, rowing, swimming as initial exercise. Avoid upright exercise until baseline stabilizes.
Start with recumbent bike or swimming 15-20 min, 3x/week. NO upright exercise initially. Increase very gradually (10% per week).
Medical Treatment Options
Discuss these options with your prescribing physician. This information is educational, not medical advice.
Pharmacotherapy (if lifestyle insufficient after 3-6 months)
Evidence: Strong for symptom management; Fu et al. showed exercise superior to beta-blockers long-term
Supplements — What the Evidence Says
Supplements are adjuncts, not replacements for lifestyle changes. Discuss with your healthcare provider.
Electrolyte Mix (functional, not really a 'supplement')
Dose: Commercial electrolyte mix (LMNT, Nuun, Liquid IV) or DIY: 1/2 tsp salt + 1/4 tsp potassium chloride + squeeze lemon in 500ml water
This IS the lifestyle intervention — electrolytes are food, not pills. Listed here for clarity.
Psychological Support and Therapy
Not typically therapy-first. If adjustment difficulty or anxiety about symptoms → CBT for chronic illness. Occupational therapy for energy management and workplace accommodations.
What People With Pots Brain Fog Say
What Helped
- • Salt loading + fluid increase — cheapest, most effective intervention. 3L water + electrolytes + salt tabs changed lives
- • Compression garments — waist-high, not knee-high. The abdomen is where blood pools.
- • Levine/CHOP exercise protocol — started recumbent, hated it, but after 3 months could walk without seeing stars
- • IV saline when available — like a brain reboot, wished it lasted longer
What Didn't Help
- • Being diagnosed with anxiety — heart rate hitting 150 just standing up and called panic attacks
- • Starting with standing exercise — told to just exercise more but standing exercise caused fainting. Nobody said start recumbent.
- • Beta-blockers alone — lowered heart rate but still exhausted because blood volume was the real problem
Common Mistakes
- • Drinking more PLAIN water (dilutes electrolytes, can make POTS worse)
- • Deconditioning from avoiding activity — POTS requires progressive exercise, avoidance makes it worse
- • Not testing for underlying cause of POTS (autoimmune, post-viral, neuropathic, hyperadrenergic)
Surprises
- • Brain fog is from BLOOD FLOW, not heart rate — compression + salt cleared fog even though heart rate was still high
- • The EDS + POTS + MCAS triad — once diagnosed with one, the other two fell into place
- • Sleeping with head of bed elevated 4-6 inches — simple, free, noticeably improved morning symptoms
"POTS brain fog is NOT in your head — it's in your blood vessels. Your brain isn't getting enough blood when upright. Salt, water, compression, recumbent exercise. Start there before anything else."
Quick Reference
Quick Win
NASA Lean Test (free, 10 minutes, at home): Lie down 5 min, measure HR. Stand against wall (without leaning) for 10 min, measure HR at 1, 3, 5, 10 min. HR increase ≥30bpm (≥40 in ages 12-19) = meets POTS criteria. Do this BEFORE spending money on doctors. ⚠️ NOT for people with heart failure, uncontrolled hypertension, or kidney disease unless explicitly cleared by your clinician.
Raj et al., Auton Neurosci, 2018; Ross et al., Clin Auton Res, 2013