Syncope: making sense of its various causes

Recently I was consulted on two patients who presented to the hospital after a syncopal episode. As syncope is relatively common, I thought that is what I should discuss in my next post.

So what is syncope? Well simply put a syncopal episode is nothing other than a fainting episode. It is characterized by momentary/ temporary loss of consciousness and posture. Patients may refer to it as I “fainted” or “passed out”.  Whenever a patient presents to the hospital after a syncopal episode we take pains to find out what led to the syncope.

So what are the different causes of syncope?  Syncope can come either from the heart or from the brain. Let me explain this further. If for some reason the heart suddenly malfunctions and stops pumping blood to the brain, you will pass out (lose consciousness). This is referred to as cardiogenic syncope. Among the various causes of cardiogenic syncope are included disorders of cardiac rhythm such as atrial and ventricular arrhythmias. Heart blocks and of course an acute myocardical infarction (heart attack) may present as a syncopal episode with the patient collapsing and passing out.

Syncope though can also come from the brain and this is referred to as neurogenic syncope or at times as neurocardiogenic syncope. This neurally mediated syncope is also at times referred to as vasovagal or vasodepressor syncope. Let me explain what vasovagal syncope is with a classical example. Lets assume you are walking on the street. A car hits a cyclist right in front of you. You rush to help the poor man. As you come near, you see him bleeding profusely, his skull cracked open. You go pale, the blood drains from your face and you pass out. There you just had a vasovagal syncopal episode. Why you may ask did you pass out?

Vasovagal syncopal episodes classically occur in the upright position meaning either you are sitting upright or standing (they usually do not occur when you are reclining). The episode is usually preceded by an unpleasant or painful episode such as the sight of blood, a medical procedure, an intense emotionally disturbing argument or news (sudden extreme emotions), standing in the hot sun or a hot shower for a long time especially if you are hungry and dehydrated at the same time.

Other less common triggers may include a bout of violent coughing (cough syncope), urination (micturition syncope) and abdominal straining as during defecation.

Usually prior to the onset of the syncope (prior to passing out), patients feel dizzy and light headed. They may complain of blurring of vision and feel as if they are about to faint. If at this stage the person sits down, they usually do not pass out or lose consciousness. This is referred to as pre-syncope (A syncopal episode was about to occur but since the patient sat down it was aborted midway).

During a vasovagal synope episode there is transient loss of the baroreflexes (this is the autonomic nervous system which helps to maintain our blood pressure). Pooling of blood occurs in the dependent calf muscles and there is lack of blood flow to the brain resulting in the patient passing out. Hence one of the simple things to do when a person has a vasovagal syncopal episode is to make them lie down flat on the ground on their back and to lift the legs above the plane of the heart. As the blood rushes back to the brain, the person quickly comes around and may look a little dazed wondering what happened.

As seizures too are associated with loss of consciousness, one always has to differentiate whether a patient had a seizure Vs a syncopal episode. As you can imagine it is important to make this differentiation as the two conditions are treated in very different ways. So how does one differentiate a seizure from a syncopal episode?

A seizure can occur with the patient in any position: sitting, standing or lying down. Syncope usually occurs in the erect posture.

Seizures are usually not preceded by the prodrome seen in syncope. Patients before they pass out in a syncopal episode complain of feeling light-headed, dizzy, room spinning and blurring of vision. Seizure patients on the other hand may give history of their aura prior to the seizure. Common auras include smelling of burning rubber, metallic taste in their mouth or a funny rising sensation in their tummy.

Patients who have a seizure and fall usually hit and hurt themselves. They fall hard and may come to the hospital with craniofacial injuries like broken teeth. Syncopal patients on the other hand do not fall hard, they rather ease themselves to the ground.

Some but not all seizures are associated with tongue biting and loss of bladder and bowel control (patient may pee on themselves and wet their pants). Most syncopal episodes are not associated with tongue biting or loss of bladder control.

Patients after a seizure are usually confused and disoriented, they may fall asleep. We call this a post-ictal state. Syncopal patients as they come out of their syncope are not confused. They know where their are and may be embrassed by the fact they fainted.

In my next post I shall discuss the diagnostic work-up and management of syncope.

Nitin Sethi, MD

45 thoughts on “Syncope: making sense of its various causes

  1. Thank you for this post. My 14 year old son has been experiencing fainting spells and has had blood work, an MRI and 2 EEG’s. Our neurologist thinks it is something vascular and his symptoms sound very much like the syncope you have described. The only time it ever happens is when he has been sitting and then stands up and stretches, bending his neck back and forth. He has had several falls that have really alarmed us, but he has come out of them with no bumps and bruises. As you described, he seems to drop to his knees on the way down and it breaks the fall. It never lasts longer than a second or two and he immediately stands back up and says he’s fine.

    I’ve been searching for articles on this and have found a few, but look forward to any additional posts you have on this topic. The more aware he has become of it, the less it’s been happening but I’m wondering if he will grow out of it?

  2. Dear Cate,
    thank you for writing in. From the history you give me, it does sound as if your son is having syncopal episodes rather than seizures. The fact it happens when he stands up, stretches and bends his neck is quite interesting. A couple of suggestions: did he have an MRI of the neck to look at the soft tissues and the carotid and vertebral arteries? Has he had a thorough cardiological examination?
    There is something called carotid sinus syncope, in which patients have a syncopal episode whenever pressure is applied on their carotid sinus. The carotid sinus are baroreceptors in the neck along the carotid artery, they help to maintain the blood pressure. In some patients they are sensitive and patients are prone to syncopal episodes and falls whenever they are stimulated.
    Continue to follow up with his doctors and I am certain they would be able to figure out the cause of his falls.
    Personal Regards,
    Nitin Sethi, MD

  3. Dear Dr. Sethi,
    I seem to have been having vasovagul syncope for at least 6 years or so. I feel that they started when I began menopause (I am now 56 and haven’t had a period for over a year. I almost always have a prodomal senation and have never actually passed out. My last episode happened yesterday at the theatre. Let me begin by saying that I take altace for high blood pressure and hychlorathyizide as a diuretic so I may have been dehydrated but I had just drunk quite a bit of water. What I am wondering instead if the lightling could have affected me. The lobby of the theatre has very dim and strange lighting that I find very disturbing. We got there early so I sat under the lighting for almost an hour. Then when we were seated, the area was fairly small and cramped. I had my legs crossed but fairly soon broke out into a sweat and began getting intestinal cramps. The feeling that I had to move my bowels became extreme and I got up to go to the bathroom but by then I was pretty woozy and weak. I managed to get to the usher but had to lie down. After a few minutes they helped me up and I laid down with my Legs elevated. I stayed in this position for only a few minutes while they got my information and I convinced the theatre staff not to call the paramedics. They helped me to the bathroom where upon I was able to evacuate and felt much better. I also drank some more water. I was ultimately re-seated on the ground floor and was able to finish watching the performance. But I have had close calls in this same theatre. It is close and crowded but I always wear sleeveless clothes so as not to overheat. I am not a nervois or panicky person. Most of my syncope episodes have been in warm places; after eating soup, having a pedicure with my feet in warm water. I can always avert the actual fainting. I have never lost consciousness. I guess what I am wondering is if lighting can have a neurological impact that would cause vasovagul syncope. I have had a number of stress tests, the last being last year, a nuclear echocardiagram; all clear. I do not think this is related to my heart but now I am wondering if I should consult with a neurologist. I would appreciate your advice. Also, very often the prodomal sensation includes a strong urge to move my bowels. Has this sensation been reported by others with syncope?
    Thank you,

  4. Dear Laura,
    thank you for writing in. It does seem you have being having what we refer to as pre-syncopal episodes (meaning a syncope like episode but not quite syncope, since you do not pass out and lose consciousness). Moreover your history suggests you feel these episodes coming-feeling dizzy, light headed, about to faint type feeling and breaking out into a sweat.
    Various factors might precipitate a syncopal episode. In the case of vasovagal syncope these might include strong emotional experiences like for example seeing blood for the first time. Strong visceral sensations may also bring on an episode. Micturition syncope has been reported in elderly men (they pass out when they get up at night to void urine). Patients have been reported to pass out as they sit on the toilet seat and exert pressure.
    It is likely that something along the same mechanism might be operative in your case. Dehydration and been in a closed crammped theatre may have further contributed to the problem. Whenever a patient presents to the hospital with syncope, we have to determine whether the cause is the heart or the brain (cardiogenic versus neurogenic/ vasovagal). Also at times it is hard to differentiate seizures from syncope.
    My advise to you would be to consult a neurologist (ask your PMD to refer you to one). I am sure they would be able to get to the bottom of your problem. Feel free to write in again.
    Personal Regards,
    Nitin Sethi, MD

  5. Dear Dr. Sethi,

    Your post on this topic is very informative. I have a seven-year old daughter who is has had several syncopes, but spread out over a long time (one at 3.5 yrs, one at 5yrs and one a month ago at almost 7 years).

    She has been seen by both a neurologist and a caridologist, but we still don’t know if she is experiencing seizures or vasovagal syncope. She has had 4 EEGs, including 72-hr. video EEG with no sign of any seizure activity. This led us to see the caridologist. He thinks it probably is vasovagal syncope based on the description of the incidents.

    What’s confusing is that the majority of the history seems to match syncope but some factors seem to match seizure.

    She was outside and standing in all 3 episodes. 2 were on very hot days — so she may have been dehydrated. She was exercising in 2 cases and had been on amusement rides in one case. In one incident, we think she tripped and scraped her leg before the syncope (may have been some very minor blood from the cut).

    Also, I have some prior history of fainting, though in my teens to early 20s. I never had episodes as young as my daughter. Mine came one when I donated blood, when I scraped myself in a bike accident and when I was overheated.

    After all 3 incidents, however, my daughter was disoriented and immediately slept after. This reaction seems to fit with seizure more than syncope. Also, in the first incident (the only one where I was present), her lips were definitely blueish. The cardiologist told me that syncope is usually characterized by complete pallor — very white whereas people having seizures are usually not white — he said they may appear flushed (red) or blueish. Also, when she was very young (12mos – 2 yrs) she had periodic staring spells that they thought might be absence seizures and daycare used to tell us that she occassionally had “drops” (vs. falls), but she never passed out with these falls.

    Lastly, I’m a little confused as to how to distinguish a prodrome and an aura. The first incident (at 3.5 yrs.) she got very upset beforehand — complained of feeling “funny” and said her tummy hurt before she lost consciousness. This was an incident that occured on a hot day, in Central Park after going on kiddie rides that had some spinning.

    Any thoughts?

  6. Dear Coleen,
    thank you for writing in. Children can have paroxysmal episodes of loss of consciousness and at times it can be extremely difficult to determine whether they are seizures or syncope. Other vascular etiologies include migraine variants which in small children can present atypically since they do not complain of headache.
    Children frequently daydream and this at times gets confused with Absence seizures. In breath holding spells a child usually after getting upset, holds his/her breath, becomes blud, may sweat and then loses consciousness and becomes limp.
    Pallid syncope usually occurs in small children and the condition resolves by itself as the child grows up.
    I am not certain what your daughter has. It may very well be syncope or some other paroxysmal disorder as I described above. At times it makes sense just to wait and watch how this condition evolves. Children frequently outgrow some conditions.
    Hope I have been able to shed some light.
    Personal Regards,
    Nitin Sethi, MD

  7. Thank you for writing in. I personally would not recommend going to a chiropractor after having a syncopal episode but I welcome your comments.

    Personal Regards,
    Nitin Sethi, MD

  8. I found your article very informative. On January 13th, 2009 my 15 year old daughter, who is on the cheer team, was cheering at a basketball game. My wife and I were both at the game (thank goodness) watching her and the game. We soon noticed Camden had left the gym floor. When she didn’t return we went over to find her on the bleachers with her head between her legs unconscious. Her face was pale white and her pulse was racing. She has fainted once or twice in the past but usually would wake up immediately and usually when she was ill. After about 5 minutes of trying to get her to snap out of it, I carried her to the car and went to the emergency room. On the way there I noticed a rash had broken out on her brow and she would stop breathing for a few seconds and then begin coughing. She finally woke up after being out for about 30 minutes. She remembered feeling dizzy and felt she should sit down before she fainted. She remembered her chest hurting badly but not much else. The ER doctor ran all of the tests but found nothing wrong with her. She took her asthma medicine that morning and had eaten breakfast and lunch. Our family doctor thinks its seizures and is recommending she see a neurologist and a cardiologist after that. My question is can I expect a conclusive diagnosis by going this route and expense or will it only be speculation?


    1. Dear Andy,
      thank you for writing in. The etiology of many fainting episodes remains undiagnosed inspite of running a battery of tests. In the case of your daughter, I am not sure what happened. The fact she says she felt dizzy and wanted to sit down indicates that she “felt it coming”. Taking that into consideration along with her age and past history of fainting makes it likely that she did have a syncopal episode. When people have a syncopal episode they are frequently pale with a rapid but thready (weak) pulse.
      A seizure and/ or a cardiac etiology for her syncope (cardiogenic syncope) remain in the differential diagnosis. My advise to you would be to request your family doctor for a second opinion. In my experience one can get a pretty good idea of the cause of the fainting by a good history and physical examination. This shall also avoid unnecessary and expensive testing.

      Personal Regards,
      Nitin Sethi, MD

  9. It sounds as if vasodepressor syncope is neurologically induced. I’m not sure I understand the neurological connection. I have been diagnosed with both supraventricular tachycardia and vasodepressor syncopy. They completed an ablation to eliminate the supraventricular tachycardia in hopes that the vasodpressor syncopy was connected and would also be eliminated. However, my symptoms have returned (although they do seem more mild). Prior to the ablation procedure, my medication (verapamil) worked great. But I’m hoping to have children, and I was told I needed to be off my medication.

    I guess all of this leads me to a few questions: 1. If vasodepressor syncopy is neurologically induced, why would my heart medication work? I understand the typical triggers for vasodepressor syncopy (an intense emotional event) and how this is neurologically induced, but mine have never occurred during an event like this. Usually, I’m just walking through a store or the hallway at work. I usually would “pass out” a couple of days after physical activity. I also have extreme fatigue, tingling in my fingers, and a numb sensation in my nose while both sitting and standing. All of these symptoms were gone while on Verapamil. 2. Is this serious? Can I just live with the symptoms, at least for a couple of years so I can have a child (from conception through breast feeding)?

  10. Dear Jessica,
    thank you for writing in. While I cannot comment on your case as I do not have all the information, it seems your “syncope” is complicated by cardiogenic causes (supraventricular tachycardia).
    The money lies in determining whether you have cardiogenic syncope or neurogenic syncope (vasodepressor syncope) or a combination of the two.
    Your cardiologist and neurologists shall be the best to decide on future course of action.

    Personal Regards,
    Nitin Sethi, MD

  11. Your article was very clear and helpful. Thank you for taking the time to maintain your site.

    I couple of hours ago, my husband was sitting upright on the couch. He started violently coughing and gasping for breath. I actually thought he was choking on something. His eyes rolled back and he lost consciousness for about 30 seconds. He then came to and was completely alert and wondering why I was screaming hysterically. Does this sound like cough syncope? In all the descriptions that I have read, it does not mention this period of gasping for breath. It was so disturbing to see, I am still shaking at the memory.

    Any thoughts you have are greatly appreciated.

    1. Dear Tabitha,
      thank you for your kind words of encouragement. Cough syncope has been well documented and does occur in circumstances similar to that which you describe with your husband. My advise to you would be to follow up with his primary medical doctor. Describe to him exactly what happened. He or she may like to run some additional tests to rule out any cardiac etiology for the above episode.
      I wish you both my very best.

      Personal Regards,
      Nitin Sethi, MD

  12. My now 17 year old daughter was diagnosed with neurocardiogenic syncope at age 14. The diagnosis came after several episodes of her passing out at volleyball practice. Most of her episodes are exercise related, a few heat induced. She normally “comes to” rather quickly and is fine after a short period of rest and fluids. They are not very frequent and she is very aware of the circumstances that normally cause her problems, and she has learned how to handle them rather well.

    My question is this:

    She is going on her Senior trip in May and one of the days they will be at an amusement park. Should she ride the roller coasters? She is adamant that she is not going to miss out on the fun, but I am concerned that if she passes out on a ride, it will cause so much commotion, and it may cause her to be very fatigued the rest of the day. Any suggestions?

    1. Dear concerned parent,
      I too feel she should not miss out on the fun. As you can see I have a weakness for roller coasters. A couple of suggestions though—ask her to hydrate herself well before getting on (now this may be tricky, I do not want her throwing up. What I am saying is ask her to hydrate herself well that morning. When she gets up have a couple of glasses of water or OJ. That shall keep her blood pressure up and avoid syncope). Also if she happens to be under the weather that day, ask her not to get on the rides.
      Easier said than done though….
      Personal Regards,
      Nitin Sethi, MD

  13. Dear Concerned Parent,
    My daughter is a 16year old cheerleader who also suffers from neurocardiogenic syncope. Her episodes started 3 years ago. In fall 2008 her episodes were occuring weekly and usually with little or no warning. She has had every test possible by her cardiologist and neurologist. After trying several medications, we ended up putting her on florinef to retain the fluid and salt and Norpace. She is doing much better, now down to an episode just once a month. This week we are going to see a chiropractor. We are hoping to eliminate the problem all together, she has hit her head 2x and had concussions.
    The reason for my letter, was to let you know that my daughter has never had a syncope episode from rides. She has been to the Disney parks, Busch Gardens and Universal in the past year. She rides all the roller coasters, and it has never induced a syncope episode. She even rides them in the heat. I do make her drink as much water and gatorade as possible prior to riding.
    I understand your concern. We live in TN and my daughter is going to spend 10 days in a very active Young Life camp in Colorado this summer. Please

    1. Dear Bernadette,
      thank you for writing in. I hope “concerned parent” and you can connect and exchange your experiences about this relatively common condition.

      Personal Regards,
      Nitin Sethi, MD

  14. Dr. Sethi,
    I can’t thank you enough for your informative post regarding different forms of syncope.
    I have a 16 yr. old daughter who was diagnosed with neurocardiogenic syncope about two years ago.
    There are a few new concerns that I have, that her cardio dr. seems to think I shouldn’t worry about. I’d like to explain the situation and would very much appreciate your thoughts on whether or not I should get a second opinion, or if you agree with her pediatric cardiologist.

    Since diagnosed with syncope, she was placed on Thermo-tabs, 1 ea. morning, another if needed midday, up to four on active or hot days with an average of 64oz. water daily. Syncope events still occur, but she’s aware of symptoms so can usually get enough water or an extra salt pill and some rest to circumvent them.

    A few months ago, she began to experience night gasping (??for lack of a better term), episodes. Just as she’s drifting off, she’ll begin to cough and then gasp. She says she feels like she can’t get enough air in her lungs. I had her take an antacid before bed for one week straight, with no change in her shortness of breath. Don’t believe it to be anxiety because she’s always nearly asleep when it occurs. It’s now occurring more frequently and just not in the evenings, usually while settling down after doing something active. (i.e. walking two flights of stairs to a class then after sitting at a desk for about five minutes.)

    Emergency room trip after one evening attack showed no abnormalities with blood work, EKG and chest xrays. We were in the waiting room for nearly 2 hrs. before she was seen and she no longer had any symptoms when she was called back. (Which I totally understand, and why I usually don’t take her to the ER because this is the norm).

    Three months ago, her biological father (who lives several states away), contacted us to report that he was diagnosed with Brugadas Syndrome and his cardiologist recommended I speak to my daughter’s cardiologist about this. When he found out that my daughter’s cardiologist didn’t respond, her father’s cardiologist tried to contact her several times to no avail. Her receptionist informed me, if her doctor thought it was important she would have called me back or spoke to her father’s cardiologist about it. That I shouldn’t worry and she’ll probably speak w/us about it at her next annual check up the end of July.

    Another issue, there are no pediatric cardio’s. who will see patients here without a referral. Can she be seen by an adult cardiologist at the age of 16? Should I just wait until July 30th for her annual or do you think that any of the symptoms she’s experiencing need to be checked out sooner?

    Sorry, this is a bit long winded and many thanks for your valuable time. Any insight or thoughts on whether or not she should have a second opinion would be greatly appreciated.

    (Don’t think it should matter but jic it does, she had Kawasaki’s at the age of 3–was treated and had no complications or lasting effects.)

    A Concerned Mom

    1. Dear Concerned Mom,
      thank you for writing in. Hmmm I shall not attempt to make a diagnosis here as I have not seen your daughter and the diagnosis of Brugada Syndrome in her biological father makes the picture even more complicated. Brugada syndrome as I remember is a disorder due to a mutation in the sodium channel (we call disorders like these channelopathies). It leads to sudden cardiac death in apparently healthy men and women due to malignant arrhythmias of the heart (disturbance in cardiac rhythm). The syndrome does have a genetic basis though I am not certain about the penetrance. While syncope and cardiac arrest are the most common clinical manifestations leading to the diagnosis of Brugada syndrome, nightmares or thrashing at night has been described. Your daughter seems to be displaying some such symptoms.
      I am not sure what plagues your daughter but I agree with you and would get a cardiologist’s opinion at the earliest.

      Please feel free to write in again.

      Personal Regards,
      Nitin Sethi, MD

  15. Dear Dr. Sethi,
    Thank you so much for your thoughtful and timely response. We will look into finding another cardiologist for a second opinion right away. I appreciate you not making me feel like a Nervous Nelly about getting a second opinion. I’ll make sure I post the results of that visit and her annual cardiology visit in July.
    Thanks once again,
    A Concerned Mom

    1. You are very welcome concerned mom. I look forward to hearing from your end again.

      Personal Regards,
      Nitin Sethi, MD

  16. In reading some of the information on syncope it was very informative.
    we have an 8 yr old granddaughter that has been complaining of headaches, that at some points are bad enough to make her cry.
    This morning she told her mother she had a headache and than she slightly stiffened, her eyes rolled back and she fell to the floor. I must explain this was first time as such. When she came to she asked what happened. Did not remember. Her mother stated that her breathing seemed to stop for minute. was going to call 911 when she came to. Mother took girl to ER . check BP, blood, and did CAT scan. Tomorrow a sleeping EEG is to be done.
    Do you have any insights.
    Thank you

    1. Dear Kathy,
      I think she warrants a thorough evaluation to differentiate seizure from a syncopal event. That would include a good EEG study.

      Personal Regards,
      Nitin Sethi, MD

  17. Hello Doctor: Last two times I have flown (airline) I have fainted during the take off. As soon as the plane leaves the ground , I feel the acceleration and the upward movement. My head spins. I don’t see anything. I am conscious. It is very scary, and very disorienting. I am immediately motion sick. I am panting (for breath.) I am miserable the entire rest of the flight. AT O’Hare, I went to the airport clinic and was given an iv.
    I am flying again for the holidays. I am very nervous at it.
    Will Bonine help?
    On take off, will putting my head between my knees help?
    This flight will be 4 hours long and if I faint there will be vomiting and four hours of misery for me and to a lesser extent, to my neighbors in the plane.
    I enjoy excellent health. Age 62, male, and on no medications.
    I do tend to dehydrate, probably from the running that I enjoy doing.
    Thank you.

    1. Dear Scott,
      thank you for writing in and I apologize for the delay in reply. No excuses apart from work. Well it seems you have severe motion/ air sickness. While meclizine may provide symptomatic relief, I would surely recommend good hydration prior to flight. Drink at least 2 glasses of water and avoid coffee and alcohol while on the plane.
      Meclizine is a vestibular suppressant and by all means try it and see how it works. You should take it an hour or so before you fly.
      Personal Regards,
      Nitin Sethi, MD

  18. I was diagnosed in my early teens with neurocardiogenic syncope with convulsions and mitral valve prolapse. Are the two related or connected in any way?

    1. Dear Anna,
      you ask a good question. Neurocardiogenic syncope is common in the teenage years. Syncope and seizures are two very different conditions. One can have what is called “convulsive syncope”. Let me try to explain this in a simple way. Let us assume you have a neurocardiogenic syncopal episode when you are with a friend. You fall/ go down. Your friend with your best intentions in his heart tries to pull you up. Now you have a condition where in there is prolonged lack of blood flow to the brain ( the best thing would have been to let you remain flat on the ground and to raise your legs). This may lead to a secondary convulsion. So you had a syncopal episode but that in turn triggered a convulsion.

      Personal Regards,
      Nitin Sethi, MD

  19. Dear Mom,
    thank you for your kind words of encouragement and thank you for writing in to me. So as has remained my principle, I shall not attempt to diagnose what plagues your daughter (since I strongly believe that the Internet is not the ideal medium for this and nothing replaces a face to face visit with the physician), I shall though give you a few thoughts. The differential diagnosis remains between a seizure and a syncope and the gold standard shall be capturing one of her typical events while she is on the EEG monitor. Ideally this should be a video-EEG study (where apart from been connected to an EEG machine, she is also been monitored by a video camera which is usually mounted on the ceiling and is synced with the EEG machine). At the same time her heart should also be monitored (EKG). If we are luckly and the events are not too infrequent, she shall have one while connected to the machine and her doctor shall be able to tell you whether it is a seizure or a syncopal episode (and if indeed it is a syncopal episode, did it come from the heart or the brain?).

    Could it be anything else? Yes the possibility of a migraine variant shall certainly cross my mind. Young children cannot express headache and in them migraine attacks can present in an atypical fashion. A number of migraine variants have been reported. Some of the common ones include:

    –abdominal migraine: usually the child complains of stomach pain and may throw up.

    –cyclical vomiting: where the child has episodes of vomiting.

    –benign paroxysmal vertigo of childhood.

    –alternating hemiplegia of childhood.

    My advise to you shall be to remain in follow up with her neurologist. He may decide to treat her for migraine. Do you have a history of migraines?

    Personal Regards,

    Nitin Sethi, MD

  20. My son is nine years old now, when he was five he hit his head on the gym wall and passes out, he also had a concussion. Through age five and six he had febrile seizures. At age five he cut his toe and while on the couch looking a his toe he turned very pale and passed out tightening and bending his arms to his chest. At age seven he was playing soccer and said he didnt feel good, he turned pale and passed out with no movements. Age eight he had been sick and taking triaminic and zyrtec felt fine then said my head and fell the the floor, he tightened and bent his arms to his chest, took to hospital and almost passed out three more times and vomited. Age nine he is running in gym and starts feeling sick to stomach, goes to tell teacher he dont feel good said he got lightheaded then on his way to sit down he falls face forward and then rolls to his side moving his legs in a running motion. All his episodes have only lasted about 30 seconds to a minute and he has always woke up fine, no confusion or anything. Could this just be syncope episodes?

    1. Dear Christy,
      thank you for writing in to me. Your son’s clinical presentation is very interesting and I do have a few thoughts. It is still entirely possible that all these episodes present vasovagal syncopal episodes (taking the circumstances under which they occurred into consideration). That said, it would be prudent that a diagnosis of seizures is looked for and ruled out and/or cardiogenic causes of syncope are ruled out. For that a EEG study shall be extremely useful. My advice would be that you should follow up with your child’s pediatrician and through him/her request a consultation with a pediatric cardiologist/ pediatric neurologist. By the way out of curiosity, does he suffer from headaches and do you have a history of migraines?

      Personal Regards,

      Nitin Sethi, MD

      1. Thank you so much for your reply. I do not have any history of migraines and the only time my son had any problems with a headache was last year when he was sick for about 3 months with sinus and coughing, which was when he had the episode when I was giving him the zyrtec and triaminic. After that time we took him to a neuro and he had a 30 min sleep deprived eeg and he also had the heart tests all came back normal, the neuro also scheduled us for a 24 hr eeg which at the time we did not do. When we took him to the neuro he said he did not think it was seizures. Of course now after the episode in gym we are going back to the neuro Tues. Im sure we will be doing the 24 hr now. But my question is will the 24 hr only show if he is having seizures in his sleep, because although my son is nine he still seems to find his way into my bed each night and he has never done anything in his sleep that i would associate with seizure activity. Since his 30 minute eeg was ok, is the 24 hr only to find if he is having them in his sleep. Also if he is having seizures is the only option giving him meds with him doing it so few times. And if it shows no seizures what’s next, where do we go from there.

  21. Dr Sethi,
    I am trying to determine whether I fainted or had a seizure Saterday night, Sunday morning. I had fallen asleep on my sofa while watching TV. My wife was in our bed and she had awoke and noticed I wasn’t in bed. She got up and woke me up which I then went into the bath room to urinate. After begining to urinate I felt my self gettting light headed and that is the last I remember until my wife finally woke me as she was on the phone with 911. I fell like a brick hitting my head on the tile. After she heard all the noise she ran in the bath room and found me on the floor. She said my eyes were opened but rolled in the back of my head and I was making a very loud growling noise which lasted for almost 2 minutes. She said my face was a gray color. I had my brother in town over the weekend and the noise I was making was so loud it woke him up on the other side of the house. He said the noise I was making sounded “wicked” like nothing he has ever heard. My wife said it was none stop until I came to. I don’t remember any of it. I was disoriented and a little confused when I came to, asked my wife who she was on the phone with and asked my brother what was he doing in the bath room. I laid on the floor for a few minutes before they had helped me to my feet and walked me over to the bed. My wife had got an ice pack for the big egg on my forhead. I felt fine the next day besides all the bumps and bruises from the fall. I called the doctor Monday and had an Ecocardiogram, EKG and a stress test done today and have a EEG scheduled for Thursday. The doctor said it was probably just a syncope. I haven’t been able to find anything regarding syncope and the loud noise I was making. The doctor has never given me an answer why I was making the noise. Any thoughts or recommedations would be helpfull as my wife is very worried and keeps having nightmares seeing me in the state I was in.


  22. I have had this fainting problem for over 10 years now, and I think it may be syncope but I have some peculiar incidences that make it difficult to be sure. If you wouldn’t mind offering your expertise I would greatly appreciate it.

    It initially started when I was 14, I was horse-riding and after jumping a course (strenuous activity) I stopped and waiting in the middle of the arena while someone else went. At this time I became very dizzy and had to get off. When my feet hit the ground I passed out. I woke up a little later, then after sitting and drinking water for approx 10 minutes I was helping out of the arena. While walking out, I passed out again. When I woke up, they wouldn’t let me walk out and instead had someone carry me into the barn. While I was being carried I passed out again. Prior to this incident there had been several occasions where I had to get off my horse early because I was lightheaded. After this incident I had my blood drawn, EKG, and MRI’s with no results. Then my doctor retired and I stopped getting tested because I was 15 and wanted to get my drivers license. My question about these incidents is about the fact that I was sitting when I got lightheaded and fainted. Is that possible with syncope?

    Over the past 10 years I have consistently had problems with getting up too fast and walking a few steps and instantly getting light headed. I can feel myself starting to lose consciousness and I try to pull it back. A majority of the time these episodes are accompanied by seizure like symptoms, usually in my legs and body. My question here is, in your article you mentioned that people with syncope don’t fall and injure themselves, and rather ease themselves to the ground. This is not always the case with me. Usually I’ll grab a wall or table, and will start seizing in the lower half of my body. Sometimes I will fall over and continue to seize for a little bit. On one occasion I fell in the bathroom, hit my chin on the counter, my ribs on the toilet seat and seized. I did not lose consciousness however, I just couldn’t control my body. Usually if I do lost consciousness, it will only be after I hit the floor, but I can always remember going down. But more often than not, I will hold on to something, seize, and then be ok. Would this be syncope?

    I am particularly confused by the fact that it happens when I go horse-riding. If I do get light headed and feel like I am going to pass out, it is always after I jumped a course or did something difficult, stopped, and was catching my breath. Then it will hit suddenly. Do you think this is more in line with seizures or syncope? And is there any way to prevent the seizing? I don’t mind the lightheadedness or even fainting, but I really wish i could make the spasms stop. You’re advice and help is greatly appreciated!

    1. I forgot to mention that when I was in high school I was suffering from headaches all the time. I used to get them 3-5 days a week and would have to go to bed with the lights off. They have stopped being a problem at some point in college I believe.
      Also, the symptoms always occur when I am upright and standing (well, when I’m sitting upright on a horse too). My blood pressure tends to be on the low end of the scale (110-100 over 60-70 ish). Light to Medium intensity cardio will send my heart rate to 180-190bpm and I am 23 years old and weigh approx 118pds. Could my blood pressure be a reason for this? Sorry for such a long post, I really do appreciate the help!

  23. Hi
    I was diagnosed with neurocardiogenic syncope and few tests were done on me “As i am reading this post i am kind of confused.
    1: Since i am diagnosed with syncope how come when i faint i go in deep sleep and i do wet myself. I never actually got hurt bc i get warned before I’m about to pass out. I had this problem since i was 17 y old and they just diagnosed me now 36 y old ..I been reading comments here and there and still don’t truly know if i have a sign of seizures and syncope at same time.This had bothered me a lot bc lot of times i had pass out when my 10 y old kid is around even that she had saved my life many time.When i pass out i was told i pea and sometimes swallow my tongue and after that i see myself in emergency.

  24. Thank you for this post, it was very informative. Today I had a very freaky incident… I was riding my horse in our weekly group lessons when after about 15 minutes of warming up and only a few laps around the arena cantering, I got a headache and quickly became light headed. I haulted and was talking to my trainer (I had calmed down, no longer dizzy) when my vision quickly became blurred and I went limp collapsing on the neck of my horse, I became very pale, my eyes rolled back and I began to shake/ tremble. This was the first time I had passed out in close to 7 years. From the ages 6-12 I passed out about nine separate occasions. And lately I have been “almost passing out” (getting light headed, blurred vision) close to once a month. Can you help me decipher what this is?

    Thank you,

  25. I just read your post and still don’t know which I have been experiencing… about 3 or 4 years ago I got up at 11:44pm to use the bathroom…(I post the time because that is the only clear memory I have) My stomach hurt and I felt like I was going to have diarrhea. the next thing i remember is my husband yelling at me to wake up. I couldn’t figure out why he was yelling at me or why he was waking up until I realized my face hurt and that I was covered in my own feces. He cleaned me up and after an hour we went to bed. He told me that I had stopped breathing for just a few moments and he gave me CPR and I began to breathe right away. The next day I went to the Doctor and I got a CT scan (1 with and 1 without contrast) which turned up nothing. They never could explain it. I hadn’t had any other issues what so ever. Last May I would experience pre-syncope episodes when I was going through a sever Asthma flare but no abdominal pain. Last night (or morning rather) about 2:44 am I experienced abdominal pain so I went to the bathroom. I urinated but could not defecate however I passed gas. I then had this feeling like I was going to throw up so I got my garbage can. The next thing I knew there I was again on the floor with my husband yelling at me to wake up but this time there was no confusion I knew what had happened. This time however I did not loose control of my bowels… I did however have severe diarrhea and vomiting all at the same time. When it had passed I went to bed but today I am very tired and a bit dazed (but that may be from the fact that I have a mild concussion) I cannot afford to go to a neurologist and the fact that the 2 times I have completely passed out were so far apart I don’t think they could really tell what is going on. So…. seizure or syncope?

  26. My 5 1/2 year old started having collapsing episodes since she was 2. Sometimes sitting on the potty with no straining. Sometimes walking or first thing in the morning. Every time she looks likes she’s dieing. Pale, deep circles under her eyes, tingling and unable to move arms or legs. We have been to neurologist, cardiologist, endocrinologist.. They can’t figure it out. When I took her off of Gluten she’s gone 8 months episode free.but then had one today.. Lasted 30 min. not sure what to do. 😦

  27. I have been searching for your follow-up “management of syncope” mentioned at the end of the Aug 2008 article.

  28. When I cough hard I go into the symtons you described. It will even happen while driving and just standing. Iam scared the someone will run into the back of me because I have to stop the car when these feeling come on, even if I am in tyhe middle of the road while driving and I may cause a accident. I have been to a Cardiologist and Neurologist and have I had every test you could amagine. But they found nothing that would cause these coughs and what would make me have the feeling of blackouts. But they don’t last long and these blackout feeling can even if happen if I am standing. Then you lose controll over standing and you stager and then fall and when you try to get up you just stager on the ground until the black out feeling and a dream feeling ends. What would you recommend I do and waht kind of test should should I ask my regular doctor to do.

  29. My son 14 year tried to hold his breath for 10 second as part of a game with his sister and he suddenly fainted. He fell on the ground and took around 5 seconds to come back to consciousness. He was holding breath while swimming and diving underwater, had not experienced this before. Is it a cause of concern?

  30. Hi Dr. Sethi,

    Thank you for your informative post. I had some concerns about my father and would greatly appreciate your expertise, if you have the time.

    My father is in his late 40s and has had about 5- 6 “episodes” over the past few years. He just had one today, after almost 1.5 years. He was walking out of the bathroom and was by the sink when he suddenly collapsed. He hit the countertop and bruised his nose. His eyes were still open but rolled back. He twitched slightly a couple of times but then stilled, which was very alarming to me. He was out for about 2 – 3 minutes. At one point, he stopped breathing and I could not feel a pulse, so I performed compressions on his chest. He then regained consciousness, but stayed lying down for about 5 minutes. He also had a loss of bladder and bowel control. He didn’t remember exactly what happened, immediately. Over the next half over, he recalled that he felt a bit nauseous and sweaty, so he was going to go wash his face. He is fine now, but he still looks weak to me. He did not let me call 911, but I have scheduled a doctor’s appointment for him for Thursday. He has seen the doctor for this same issue in the past, but they only conducted a blood test and sent him home.

    One thing I noticed is that about 4 out of his 5-6 incidents happened after he had 1-2 drinks of scotch. He is not an alcoholic and only drinks at social gatherings, but could this be related in any way?

    I would appreciate any thoughts you could share.


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