POTS, Migraines, and Heat Intolerance

The summer is here and so is one of my favorite celebrations - Out! Raleigh Pride! As a queer owned physical therapy clinic, I'm particularly aware that emerging research suggests that conditions such as migraines, POTS, and other dysautonomic conditions occur at a much higher prevalence in the LGBTQ+ community, but whether you're a part of the LGBTQ or not, I wanted to share some quick tips on how to stay safe in the summer heat. Click here to jump to heat safety tips, or

continue reading to learn more about POTS and Migraine.

First of all, what is POTS?

Postural Orthostatic Tachycardia Syndrome (POTS) is a form of dysautonomia in which the autonomic nervous system fails to properly regulate circulation upon standing. When an affected person moves from lying to upright, blood pools in the lower extremities and the heart races to compensate. A rise of 30 or more beats per minute (bpm) within 10 minutes of standing, or a heart rate at or exceeding 120bpm u

pon standing is considered a positive test for POTS. Other tests may be performed as well to help diagnose this condition.

Symptoms go beyond a fast heart rate and commonly include lightheadedness, brain fog, fatigue, nausea, and exercise intolerance. The condition affects people assigned female at birth more often than people assigned male at birth, and amongst those, the majority fall within the age range of 15-50. Most often, it follows a triggering event such as a viral illness, trauma, or pregnancy.

Management is multimodal and may include high sodium and fluid intake, compression garments, graded exercise, and medications targeting heart rate or blood volume. Physical therapy plays a meaningful role through progressive exercise reconditioning and nervous system regulation strategies.

What is migraine?

Migraine is a complex neurological disorder characterized by recurrent attacks of moderate to severe head pain, typically unilateral and pulsating, often accompanied by nausea, light sensitivity, and sound sensitivity. Attacks can last anywhere from a few hours to several days and are frequently preceded by prodromal symptoms or, in about a third of patients, an "aura" which is a transient neurological disturbance such as visual changes, numbness, or speech difficulty.

The underlying mechanism involves trigeminovascular activation, cortical spreading depression, and dysregulation of pain processing pathways. Migraine is not simply a headache, it is a whole-brain event with significant systemic involvement.

Triggers vary widely and may include hormonal fluctuations, sleep disruption, stress, dietary factors, vestibular input, and sensory overload. Many patients also have central sensitization, meaning their nervous system is chronically amplified and reactive.

Treatment spans acute and preventive categories, from triptans and gepants to CGRP monoclonal antibodies, behavioral strategies, and neuromodulation. Physical therapy addresses contributing factors including cervicogenic components, vestibular dysfunction, postural load, and nervous system dysregulation - making it a valuable part of a comprehensive migraine management plan.

Why are people with POTS and migraine less tolerant of the heat?

Heat intolerance in both POTS and migraine comes down to a shared problem: an autonomic nervous system that is already working overtime and has very little reserve when additional physiological demand is placed on it.

In POTS, heat causes cutaneous vasodilation where the blood vessels near the skin surface dilate to facilitate cooling. For someone with healthy autonomic function, this is compensated for automatically. In POTS, that vasodilation compounds the existing problem of poor venous return, pulling even more blood away from central circulation. Heart rate climbs further, symptoms escalate, and the system essentially hits a wall.

In migraine, heat acts as a potent trigger through several mechanisms. It stresses the hypothalamus, which plays a central role in both thermoregulation and migraine generation. It promotes dehydration and electrolyte shifts, which lower the threshold for attack. It also drives vasodilation and increased cerebral blood flow, which can activate trigeminovascular pathways. For patients with central sensitization, even modest thermal changes can be enough to tip the nervous system into a pain state.

The overlap matters clinically because POTS and migraine co-occur at high rates. Both reflect underlying autonomic and central nervous system dysregulation, and heat destabilizes both systems simultaneously. Patients dealing with both conditions often find that warm weather, hot showers, or prolonged outdoor exposure reliably worsens their entire symptom picture. Cooling strategies, hydration, and sodium loading are foundational management tools for exactly this reason.

How to stay safe in the heat:

General Foundations: These apply any time temperatures rise, not just at events.

Hydration

• Water alone is not enough. You need electrolytes, particularly sodium. LMNT, Liquid IV, Nuun, or simply water with added salt and a squeeze of citrus all work. Drink before you're thirsty — thirst means you're already behind.

• For POTS specifically, sodium loading is therapeutic. If your provider has cleared it, lean into high-sodium foods and drinks, especially in the morning before you've been upright long.

Compression

• Compression garments reduce venous pooling and help your body maintain circulation when heat is pulling blood toward the skin. Knee-highs, thigh-highs, abdominal binders, and full leggings all have a role. Wear them consistently so they feel normal.

Cooling Strategies

• Cold applied to the neck, wrists, and inner elbows cools core temperature quickly. Cooling towels, ice packs wrapped in cloth, and cold water immersion of the hands and forearms are all effective.

• A small battery-powered fan paired with a damp cloth dramatically increases evaporative cooling.

• Cool (not ice cold) showers before heat exposure can help pre-cool your system.

Pacing

• Heat is a physiological stressor that compounds fatigue, dysautonomia, and migraine susceptibility. Treat it like any other exertion. Build in rest before you feel like you need it.

• Avoid prolonged standing when possible. Shifting weight, walking slowly, or sitting beats standing still every time.

Medications and Sleep

• Take preventive medications consistently. Don't skip doses around high-demand days.

• Keep rescue medications accessible at all times — triptans, anti-nausea meds, whatever your acute protocol is.

• Sleep is non-negotiable. Poor sleep raises migraine threshold and destabilizes autonomic function the next day.

Heat Acclimatization

• Short, controlled heat exposures over days to weeks can modestly improve tolerance. Step outside for 10 to 15 minutes, cool down, repeat. Don't push into symptoms.

Getting Ready for Out! Raleigh Pride

Starting Now

• Begin increasing your hydration and electrolyte intake today.

• Start wearing compression daily if you aren't already.

• Practice short outdoor exposures to begin mild acclimatization. Start with 5 minute walks outside, and work incrementally.

• Scout the Pride route, rest stops, shade, and any air-conditioned spaces. Knowing your exits in advance reduces cognitive load on the day itself.

  • Headway Physical Therapy is creating an interactive map of allied businesses along the festival route that can provide an AC'd space to take a break. The map will be marked with accessibility features like whether or not it is wheelchair accessible, if there will be water, if there will be outlets for charging medical devices...etc. Follow Headway Physical Therapy on instagram or return to this page on the day of the festival for a link to the map!

The Week Before

• Pre-hydrate heavily in the 2 to 3 days before the event.

• Avoid alcohol and limit caffeine, both of which are dehydrating and lower your migraine threshold.

• Get prescriptions filled and prepare your go-bag ahead of time.

• Protect your sleep, especially the night before.

On Pride Day (June 27th for Out! Raleigh Pride)

• Hydrate and eat a real meal before you leave the house.

• Dress in lightweight, light-colored, loose-fitting clothing. A wide-brimmed hat is highly effective.

• Pack a cooling kit: cooling towel or neck wrap, small fan, refillable water bottle, electrolyte packets, and rescue medications.

  • Headway PT will have a tent off Fayetteville Street for pride that will provide battery operated portable hand fans, paper fans, water bottles, and a place to rest with tables, chairs, and yoga mats to help you stay safe! The tent will be identified on the interactive map mentioned earlier!

• Wear your compression garments if you have previously responded well in the heat with compression garments on.

• Use rest stops proactively. Sitting before you feel bad is far more effective than recovering after you've already crashed.

• Buddy up with someone who knows your conditions and what early warning signs look like such as pallor, sudden quiet, confusion, or increased clumsiness.

• If warning signs of presyncope or migraine appear: get out of the sun immediately, sit or lie down, cool the back of the neck, and drink electrolytes.

• Have a low-guilt exit plan. Knowing you can leave without it being a failure makes it easier to pace well and actually stay longer.

Do you feel you will benefit from starting a physical therapy program?

Looking to get ahead of your symptoms before Pride? Headway PT specializes in the treatment of neck pain, headaches, migraines, vestibular dysfunction (dizziness), concussion, and other dysautonomic disorders. Check out our clinic here, or click below to book an evaluation with someone whose values align with your own, and start making Headway today!

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