Maria
I want to tell you about a patient — I'll call her Maria, though the details are changed to protect her privacy. When Maria first came to see me, she wasn't walking to the bathroom. She was crawling. Every time she stood, her heart would race, the room would spin, and she'd end up on the floor. She'd been to three emergency rooms and been told, more than once, that it was anxiety.

It wasn't anxiety. It was POTS — Postural Orthostatic Tachycardia Syndrome — and Maria's story is one I'm seeing more and more often since 2020.

Why you're hearing about POTS more than you used toPOTS isn't new. But it's become dramatically more common since the COVID-19 pandemic. A large U.S. database study tracking POTS diagnoses before and after 2020 found the incidence rate jumped more than tenfold — from about 1.4 cases per million person-years before the pandemic to over 20 per million after it, with new diagnoses climbing steadily into 2023. Some of that rise likely reflects better awareness and more doctors thinking to test for it. But the researchers behind that study, and others since, believe a real biological effect from COVID-19 infection itself is also driving new cases. POTS now appears to be one of the more common, and more treatable, faces of long COVID.

Dysautonomia: the umbrella term
POTS is one member of a larger family of conditions called dysautonomia — a general term for anything that disrupts the autonomic nervous system, the part of you that runs on autopilot: heart rate, blood pressure, digestion, temperature regulation. Dysautonomia isn't one disease; it's a category. POTS lives inside that category, alongside other conditions like neurocardiogenic syncope (the common fainting spell) and orthostatic hypotension.

What's actually happening in the body?
When you stand up, gravity pulls roughly half a liter of blood down into your legs and abdomen almost instantly. In a healthy system, the autonomic nervous system compensates in a fraction of a second — blood vessels constrict, heart rate ticks up slightly, and blood pressure holds steady. In POTS, that compensation is faulty, and there isn't one single agreed-upon reason why. A few explanations show up repeatedly in the research:

• Low blood volume (hypovolemia). Many POTS patients are running with less circulating blood volume than they should have, so there's simply less to work with when gravity pulls blood downward.
• Faulty vessel constriction. In some patients, the nerves that should tighten blood vessels in the legs on standing don't fire strongly enough, so blood pools instead of getting pushed back up — the heart then races to try to compensate for the drop in return.
• Autoimmunity. A growing body of research points to autoantibodies that interfere with receptors involved in blood vessel and heart rate regulation, particularly in cases that follow a viral illness.
• Post-viral triggering. This is where COVID-19 fits in. One proposed mechanism is molecular mimicry - the immune response to the virus ends up cross-reacting with the body's own nerve tissue, disrupting autonomic signaling afterward.

None of these are mutually exclusive, and different patients likely land in different buckets.  This is part of why POTS treatment is individualized rather than one-size-fits-all.

POTS vs. orthostatic hypotension -  same neighborhood, different house
These two get confused constantly, including by physicians who don't specialize in this, so let's be precise:

• POTS: When you stand up, your heart rate climbs excessively — by 30 beats per minute or more in adults (40+ in teenagers) within about 10 minutes of standing — while your blood pressure stays relatively stable. Your body is compensating for a circulation problem by racing the heart instead of losing pressure.
• Orthostatic hypotension (OH): When you stand up, your blood pressure itself drops significantly (a drop of 20 mmHg systolic or 10 mmHg diastolic within the first few minutes of standing). Heart rate may or may not change much.

Here's what makes them feel so similar: both are triggered by standing, both come from blood pooling in the legs instead of getting back to the brain efficiently, and both can produce the same dizzy, foggy, about-to-pass-out feeling. The difference is how your body tries (and fails) to compensate — with a racing heart in POTS, or with an outright pressure drop in OH. Diagnosing correctly matters, because the medications that help one can sometimes worsen the other.

A simple at-home self-check
Before you ever get to a specialist or a formal tilt table test, there's a rough screening test you can do at home with nothing more than a home blood pressure cuff and a clock. It's sometimes called the "poor man's tilt table test," and it's a simplified version of the standing tests used in autonomic clinics.

1. Lie down for 5 minutes before your first reading. Rest quietly, flat on your back, until you feel settled. Take your blood pressure and pulse. This is your baseline.
2. Sit up and check again. Take another reading a minute or two after sitting.
3. Stand up and check at intervals. Take your blood pressure and pulse right after standing, then again at 1, 3, 5, and 10 minutes if you can tolerate it. Standing still (not walking around) matters — leaning your shoulder blades against a wall, heels a few inches out, makes it easier to hold position.
4. Write down the numbers — all three positions, with times — to bring to your doctor.

What you're looking for:

• A heart rate rise of 30 bpm or more (40+ if you're a teenager) between lying down and standing, without a significant blood pressure drop, points toward POTS.
• A blood pressure drop of 20 mmHg systolic or 10 mmHg diastolic or more on standing points toward orthostatic hypotension instead.

A word of caution: please don't do this alone if you have a history of fainting. Have someone nearby, and stop and sit or lie back down right away if you feel like you're going to pass out. This test doesn't replace a formal diagnosis — some people need a full tilt table test or additional autonomic testing to sort out what's really going on — but it's a genuinely useful first data point, and it's the same basic information I ask nearly every new patient with these symptoms to gather before our first visit.

Maria's turnaround
Back to Maria. We didn't start with anything exotic. In order:

1. Water — a real volume, not a gesture. Most POTS patients are chronically underfilled on blood volume relative to what their circulation needs. We built her up to roughly 2.5–3 liters a day.
2. Salt and electrolytes. Sodium holds water in the vascular space. Adding electrolyte mixes and increasing dietary salt gave her fluid intake somewhere to stay.
3. Compression garments. Waist-high compression (not just knee-highs) counteracts the blood pooling in the legs and abdomen that starts the whole cascade.

These three alone took her from crawling to walking with a cane. Then we added the right medication for her physiology, and that's when things really turned — steadier heart rate, fewer crashes, days she could plan around instead of days that planned around her. At one point her volume depletion was severe enough that we sent her for IV fluids at the hospital, and that single infusion reset her system in a way oral fluids alone couldn't. That combination — fluids, salt, compression, targeted medication, and IV support when truly needed — is what got her her life back.

If this sounds like you
POTS is real, it's measurable, and — especially since 2020 — it's far more common than most people realize. If standing up reliably makes you dizzy, foggy, or leaves your heart racing, this deserves a real workup, not a shrug. It's treatable, often with tools far simpler than people expect.

(And if your blood pressure actually rose rather than dropped when you did the home test above — that's not a fluke. There's a whole subtype, hyperadrenergic POTS, that looks different and is treated differently. More on that in a future post.)​

Selected sources: European Heart Journal – Quality of Care and Clinical Outcomes (2025) on POTS incidence pre/post-COVID; Johns Hopkins Medicine, POTS overview; Frontiers in Neurology (2026) on POTS vs. orthostatic hypotension classification; PMC (2025) review on COVID-19–induced POTS mechanisms (hypovolemia, autoimmunity, molecular mimicry); Frontiers in Medicine (2026) on POTS and platelet storage pool deficiency in long-haulers; Bateman Horne Center, 10-Minute NASA Lean Test clinician protocol, on at-home/passive standing test procedure and diagnostic thresholds.

Why Everything Makes You Flare: Understanding MCAS


Do you avoid the detergent aisle at the grocery store? Does it feel like your body is reacting to everything — food, stress, weather changes, supplements — even things that used to feel totally fine?
You’re not imagining it.
This is something I hear from patients all the time, especially those already dealing with complex, chronic symptoms. They’ve tried different things, seen multiple providers, and they’re still asking the same question:
“Why do I keep flaring?”
One piece of the puzzle that often gets missed is Mast Cell Activation Syndrome, or MCAS.
When Your Body Is Always “On Edge”
Mast cells are a type of white blood cell — part of your immune system’s first-responder team. Think of them like a guard dog. When something concerning shows up, the dog runs to the door and barks. That’s normal, that’s healthy.
But in MCAS, the system gets dysregulated.
Your dog doesn’t just bark when someone’s at the door — it barks when you sneeze, drop a pencil, or stand up too fast. You don’t have a guard dog anymore. You have a pack of yapping chihuahuas.
Inside each mast cell are packets of chemical messengers ready to be released — histamine being the most well-known, but there are hundreds of others, including leukotrienes, heparin, and elastase. When these get released, they create the symptoms you feel. And then your body has to clean them all up, which takes nutrients and processes like methylation. This is why symptoms can feel so widespread and hard to pin down.
Why You Keep Flaring Even When You’re Doing Everything Right
This is one of the most frustrating parts of MCAS. You can genuinely be doing all the right things and still flare.
That’s because the problem isn’t just what you’re being exposed to — it’s how reactive your system has become. Your body has lost its tolerance buffer. So instead of handling stress, food, or environmental triggers without much trouble, everything stacks up until you hit a threshold, and then you crash.
This is why so many people tell me things like:

• “My safe foods keep changing.”
• “I can’t figure out my triggers anymore.”
• “Every time I make progress, I crash again.”

It’s not random. Your system is flooded with danger signals, and your mast cells are responding to nearly everything as a threat.
What’s Often Being Missed
What I see a lot is that people have been trying to manage their symptoms, but no one has really looked at what’s driving the reactivity itself.
MCAS rarely exists on its own. It’s often connected to things like:

• Chronic infections (Lyme, for example)
• Mold or toxin exposure
• Gut dysfunction
• Chronic inflammation
• Nervous system dysregulation
• Hormonal imbalances

When these aren’t addressed together, the body just stays stuck in that reactive state — and the flares keep coming.
What About Antihistamines and Low-Histamine Diets?
These are usually the first things people try, and they can help — but they don’t get to the root of what’s happening.
Antihistamines are a bit like noise-canceling headphones. The chihuahuas are still barking, you just can’t hear them as much.
Low-histamine diets can reduce symptoms, but they’re hard to follow consistently, and they’re affected by so many other factors — stress, sleep, illness, environment. What’s fine one day might trigger you the next. These tools have their place, but they’re not the whole answer.
This Can Get Better
Here’s what I want you to know: you are not “too sensitive.” You are not going to be reacting to everything forever.
In the short term, the goal is to stabilize the mast cells — to calm the system down. There are both natural and conventional ways to do this, and finding the right fit really does need to be individualized, especially for people who are highly sensitive.
Over time, the work is about reducing the underlying triggers — toxins, infections, ongoing stressors — while supporting your body’s ability to process and recover and slowly rebuilding tolerance.
A Patient’s Story
One of my patients, Susan, came in frustrated and confused.
She had been slowly limiting her diet and reducing her exposures more and more, trying to get ahead of her flares — but it wasn’t really working. Sometimes she was completely fine. Other times, it felt like anything could set her off: a supplement, a food she’d eaten a hundred times before, a temperature change, a stressful day, even her period.
When she did flare, it hit her from all directions — anxiety, insomnia, skin reactions, brain fog, migraines, gut changes. It was exhausting, and it made no sense to her why some days were okay and others weren’t.
What we found was that her system wasn’t just reacting to triggers — it was stuck in a highly reactive state. So instead of chasing each individual trigger, we focused on stabilizing mast cell activity, supporting her gut, calming her nervous system, and introducing any new support slowly, at a pace her body could actually handle.
Within a few months, things started to shift. Her flares became less frequent, then less intense, then more predictable. She realized she could reliably make plans again, think ahead about meals, and even tolerate foods she’d been avoiding. For the first time in a long time, she felt stable enough that we were ready to take next steps.
If you’re reading this and thinking this sounds exactly like what’s been happening to me, it might be worth looking more closely at what’s really going on. There is a reason your body is responding this way — and there’s a path to feeling better.
I’ve been working with patients on complex, chronic symptoms for over 15 years. If this pattern feels familiar, feel free to schedule an appointment and we can dig into your specific situation together.
​
(MCAS is complex and can have a genetic component too. In a future post, I’ll talk about how conditions like hypermobility and Ehlers-Danlos Syndrome can fit into this picture.)

​Yesterday I was bringing in mustard greens and arugula from the garden for our dinner salad, and I accidentally brought in something else, someone who was really not happy about this change in her afternoon plans. I was notified of her displeasure by a sharp jab in my right thumb. 

Good thing I was making salad dressing - a quick peel & cut of a garlic clove, a moment of discomfort as I pressed the cut clove to the sting, and a few minutes of inconvenience as I held it to the area, and I was all better. 

This is somewhat amazing to me, as my reaction to something as humble as a mosquito bite is a huge welt and days of itching. 

Garlic works on bee and wasp stings just as it works in your marinades - it breaks down the proteins. The proteins are what your body reacts to, the inflammation around a bee sting is a result of your body trying to break down those proteins so they can't hurt you. When garlic is applied immediately to an insect sting, it removes the need for your immune system to respond. And so today I have a working thumb instead of a huge sausage. 

What are YOUR kitchen cures for bee stings? Leave your comments below.

​If you've been tested for MTHFR and it's come up that you're heterozygous or homozygous for one or both of the SNPs, chances are that someone has told you you need to take methylated B12 and folate, and someone else has told you NOT to, because you could end up overmethylated.  What's a poor MTHFR to do?  

Well, I just found a real nugget at mthfr.net -  a quick & easy test to see if you're overmethylated (and need to take a non-methylated version of B12 like hydroxycobalamin) or whether you're undermethylated, and desperately need methylcobalamin, the methylated form of B12.

Ready?  Here goes:

Methods to Understand if You’re Hypomethylated or Hypermethylated

"Take some Niacin in the form of nicotinic acid. Chew 1/10th a tablet of Niacin and then swallow. Niacin utilizes s-adenosylmethionine (SAM) when breaking down. If you flush strongly on 50 mg, you are likely hypomethylated (lack of SAM). If you do not flush much, you are likely a ‘normal methylator’ (balanced SAM). If you do not flush at all, you may be hypermethylated (excessive SAM).

Side Effects from Methylfolate: If you are taking methylfolate and experiencing these side effects, then you are likely hypermethylated."

Simple, right?   

Well, except for those who are hypomethylated and then get hypermethylated due methyl trapping from problem SNPs further on down the line. But if that happens, just nibble on some more niacin, and schedule with your MTHFR doctor.

It's that time of year.  Finally the tourists are gone, the weather is perfect and the traffic is manageable, but we are not in the clear.  We have another crop of visitors who may even more irritating than the group house next door. Relatively recent immigrants to the area, they have been showing up more and more frequently on resident ankles and feet.  Those with history in the South call them chiggers, as the multitude of incredibly itchy bites strongly resembles an exposure to chiggers.  The folks at Cornell University Extension have done research, however, that shows these unwelcome visitors to be Lone Star Tick larvae.

One last piece of bad news - these larva can be enough to produce the Alpha-Gal allergy, the one that makes people into instant, unwilling vegetarians. ( A quick visit to the ER for anaphylaxis after eating meat will convince anyone to give it up.)  Again, we find that the Hamptons are a special place - one of only two areas in the country with a large number of residents with Alpha-Gal allergy (more on this in a future post).

Now for the good news.  You CAN stop the itch. 

Apply  a thin layer of oil (any kind, although I prefer castor oil because it contains its own healing properties) followed by a sprinkle of CAYENNE PEPPER.  Yes, cayenne.  No, it doesn't burn.  What it does is deplete Substance P, a molecule that carries pain signals to the brain.   And makes you STOP ITCHING.  Almost instantly. Covering the area with an old sock will keep the cayenne from brushing off on your clothing or furniture.  Reapply as necessary.  ​

Hallowe’en – an entire day, even week, devoted to collecting candy.  If you’re a parent trying to get your kid to eat healthfully, this holiday can be one of the most challenging.  What’s a parent to do?  :
 

1. Don’t take the fun out of it.  Emphasize other aspects of the holiday – the costume, the parties, the parades, the decorations, pumpkin carving.  You can even get your kids out in nature, picking pumpkins and apples, playing in the leaves, and so forth.
2. Make sure they have a hearty, healthy dinner before trick or treating, with lots of protein and healthy fats and vegetables, and as few simple carbohydrates as possible (this is not the night for pasta or pizza) – try burgers with no buns, roast chicken with vegetables, or chili con carne; if you’re a more adventurous parent, or have some extra time, you can make some of the Halloween themed foods that show up online this time of year like this “feet loaf” recipe  http://www.instructables.com/id/Feet-Loaf-Disgustingly-Delicious-Simple-Main-dish/
3. Have them WALK to trick or treat – all that running around and excitement will make it easier for their body to process the sweets.  Research shows that the only time when simple sugars are processed well is after intense exercise. 
4. Don’t fight your kids about candy or reward them with candy.  Research shows that when you make something a reward such as  “only after you eat your vegetables” it makes vegetables a chore and sweets a treat and sets up unhealthy eating habits and a lifetime of turning to sweets when you need rewards. 
5. Teach self-awareness: If your kids over-indulge, talk to them about how they feel – get them to tell you about the belly ache or the crazy feeling inside – so they have an internal sense of what it means to eat too much
6. Reduce the amount of candy they keep Many parents will pay their children for each piece of candy – depending on the size of their haul, anywhere from a nickel to a quarter a piece.  Then they can spend it on a toy, book or puzzle of their choice.
7. Don't have the candy in the house for weeks – sugar is a HABIT, and having a little every day will set up a cycle that will be hard to break, especially with the other sweet-laden holidays that are fast approaching.   So far, I have not thought of any amazing ways to remove a bag of candy from a child who has collected it, except #6 above.   If you have, please submit it in the comments below!! 

 
What are your best pointers for a Healthy Hallowe’en? Leave your tips below.