POTS and Long COVID: How Dysautonomia Shows Up After COVID

Are POTS and Long COVID the Same Thing?

Long COVID is recognized as a condition associated with autonomic nervous system dysfunction (Camargo, 2026). That's the system that runs heart rate, blood pressure, digestion, sweating and temperature without you thinking about it. Dysautonomia is the umbrella term for problems with it, and POTS is one form of dysautonomia. POTS means a sustained heart rate rise of 30 or more beats per minute within 10 minutes of standing (40 or more in teens), with symptoms lasting at least 3 months and no drop in blood pressure (Vernino, 2021).

A 2026 study of 100 long COVID patients concluded that dysautonomia is common in long COVID and contributes to its symptoms (Tamariz, 2026). That was a single snapshot of 100 patients, so it shows how often the 2 appear together and can't show that one causes the other.

Our team treats either label as a starting point. Dizziness after COVID can come from more than one mechanism, so the clinic measures what heart rate, blood pressure and brain blood flow do when you stand before deciding what the dizziness means.

How Common Is POTS After COVID?

How often POTS shows up in long COVID depends on who was tested, and 3 studies give 3 different answers.

The first was a cross-sectional study of 100 consecutive long COVID patients enrolled in clinical research studies. POTS was found in 10% of them. Dysautonomia, defined as an abnormal score on the COMPASS-31 autonomic symptom questionnaire, was seen in 82% (Tamariz, 2026).

The second tested 50 patients at a dedicated long COVID clinic with a lean test. Postural orthostatic tachycardia, a fast heart rate rise when upright, showed up in 16 of the 50 (32%). Postural orthostatic hypotension, a blood pressure drop when upright, also showed up in 16 of the 50 (32%) (O'Brien, 2026).

The largest of the 3 looked back at 143 long COVID patients who had autonomic testing at one hospital lab. 22% met POTS criteria, and 92% had reduced brain blood flow when upright (Novak, 2026). Those were patients sent for autonomic testing, so the rates are likely higher than in long COVID overall.

Study 1: 100 long COVID patients from research studies (Tamariz, 2026)

Abnormal autonomic questionnaire82%

POTS10%

Study 2: 50 patients at a long COVID clinic (O'Brien, 2026)

Fast heart rate rise upright (16 of 50)32%

Blood pressure drop upright (16 of 50)32%

Study 3: 143 long COVID patients at an autonomic lab (Novak, 2026)

Reduced brain blood flow upright92%

POTS22%

The first 2 samples are small, and all 3 came from research or clinic settings, so none of them gives the rate of POTS across everyone who has had COVID.

Why Do Long COVID Heart Rate Spikes and Dizziness Hit When You Stand?

When you stand, gravity pulls blood away from your head. Our team sees the heart rate spike that follows as the body's rescue for brain blood flow. In long COVID, the clinic reads the question as which part of brain blood flow control the infection left behind, and the racing heart as the heart covering for it.

In our team's view, dizziness on standing is what falling brain blood flow feels like, whether or not the heart manages to compensate. That's why a normal heart rate doesn't settle the question. In the largest study above, 92% lost brain blood flow upright while 22% met POTS criteria (Novak, 2026), and a 2025 review notes that in many orthostatic intolerance syndromes, heart rate and blood pressure often look normal while that happens (Khan, 2025).

Lying down Standing up

Replay

CO2 matters too, because in the clinic's explanation, low CO2 narrows the brain's blood vessels. In the 50-patient clinic sample above, 32 (64%) had low CO2, either lying down or upright (O'Brien, 2026). The same study found that symptoms improved after breathing rehabilitation whether or not CO2 changed, so how much low CO2 drives symptoms in long COVID is still an open question. Low CO2 driving low brain blood flow is called hypocapnic cerebral hypoperfusion. In our team's view, brain fog that gets worse upright most often comes from the same drop in flow.

What Does Dysautonomia After COVID Look Like?

After COVID, dysautonomia can show up as a racing heart or dizziness on standing, brain fog, fatigue, trouble with exercise, and changes in digestion, sweating or temperature control. A tilt-table study compared 39 long COVID patients with 22 healthy controls using heart rate variability and blood pressure, and found marked autonomic dysfunction during tilt in the long COVID group (Camargo, 2026).

A related finding comes from 169 consecutive long COVID patients referred for orthostatic intolerance: 81% had central sensitization, a heightened pain and sensory response. The authors conclude that central sensitization appears highly prevalent in long COVID and may contribute to its multisystem symptoms. They also write that cerebral hypoperfusion and neuroinflammation "may constitute pathophysiological mechanisms" behind it, which the study raises as a possibility without testing cause and effect (Novak and Iyer, 2026).

Long COVID also shares much of its autonomic picture with ME/CFS. The 2026 study above ran the same autonomic tests on both groups and found reduced brain blood flow upright in 92% of 143 long COVID patients and 88% of 170 with ME/CFS. Its authors suggest the 2 may share mechanisms, while noting that those mechanisms remain poorly understood (Novak, 2026).

Is Autoimmunity Behind Long COVID POTS?

Many people our team sees with POTS after COVID arrive with positive autoimmune bloodwork. The question is whether the autoimmune finding is a downstream result of low brain blood flow or the thing driving the dysautonomia. The clinic's answer is that it could go either way.

Our team thinks about the immune system the way it thinks about a reflex. When a tendon is tapped, the response should land in the middle. A response that's too brisk usually points to the brain or spinal cord, and one that's too weak points to the peripheral nerves or the cerebellum's output. In the clinic's model, the immune response has the same kind of sweet spot, and a response can be too strong, too weak, or a downstream reaction to something else.

That model leads to 2 questions. The first is whether the body is responding to too much of something it has to clear. The second is whether the brain is misjudging how big a response a stimulus calls for. That's a signaling question, and it's the part our team looks at. It's the clinic's working model, and it hasn't been tested in a study.

How Has COVID Changed POTS Care?

Our team's view of how COVID changed POTS comes from day-to-day experience, and the clinic is clear that this is observation: "This is not a meta-analysis. This is not peer-reviewed. This is just like my observation of the day-to-day."

Before COVID, most of the POTS our team saw was skewed toward concussion and brain injury. COVID brought infections such as Epstein-Barr into the picture as triggers, along with a large influx of patients with patchy, Guillain-Barre-like nerve involvement across the sensory and motor systems.

Most of the COVID-related cases the team sees today center on an auto-regulatory error, where the normal reflexes of the blood vessels in the brain stay impaired. The goal hasn't changed: solve for the underlying mechanism instead of chasing each symptom. Our team also sees post-vaccination syndrome, when symptoms like these start after a COVID vaccine.

How Is POTS After COVID Treated?

Medications can ease symptoms and serve as a bridge, and they have a ceiling: they don't change why the brain loses blood flow upright. Our team leaves existing medications alone at first, and changes to them stay with your prescriber. In the 50-patient clinic study above, the 13 patients who finished breathing rehabilitation had lower POTS symptom scores afterward (O'Brien, 2026). Our team's approach is on the long COVID treatment page.

What Can't the Research Tell You Yet?

A 2026 systematic review of 42 studies of brain changes in long COVID found the evidence limited by "substantial heterogeneity in study populations, assessment techniques, and reported outcomes" (Moraes, 2026).

One case report shows why brain imaging is hard to read in long COVID. It found relative differences in brain perfusion in one patient with persistent cognitive and vestibular symptoms after COVID. Its authors write that the link to the patient's symptoms remains uncertain and that a single observation doesn't establish the diagnostic or clinical value of the scan (Pham, 2026).

People also ask whether there's a window after which recovery stops. Our team's position is that the nervous system has no hard cutoff for change, and many people the clinic sees first come in years after their symptoms began. The best day to start was before you noticed a problem, and the second best day is today. Whether POTS can be cured is its own question, answered in Can POTS Be Cured?

Where Should You Start if Your Symptoms Began After COVID?

Start with the mechanism: the clinic's testing measures brain blood flow with transcranial Doppler while you're upright, alongside heart rate and blood pressure, so a normal pulse can't hide a drop in flow. The POTS and dysautonomia pages explain how our team approaches each condition.

POTS and Long COVID: FAQ

← Back to Blog