Midodrine and Multiple Sclerosis: Can It Help with Low Blood Pressure?
Nov, 1 2025
People with multiple sclerosis (MS) often struggle with more than just muscle weakness or fatigue. One of the most disruptive, yet rarely talked about, symptoms is orthostatic hypotension - a sudden drop in blood pressure when standing up. This isn’t just dizziness. It can lead to fainting, falls, and a loss of independence. For many, the solution isn’t a new drug for the brain, but one that works on the blood vessels: midodrine.
What Is Midodrine?
Midodrine is a medication approved by the FDA in 1996 to treat orthostatic hypotension. It’s not a heart stimulant or a caffeine pill. Instead, it works by tightening small arteries and veins, which helps push blood upward when you stand. The active form, desglymidodrine, binds to alpha-1 receptors in blood vessel walls, causing them to contract. This raises blood pressure - especially when you’re upright.
It’s taken orally, usually three times a day, about 30 minutes before meals. The typical dose ranges from 5 to 10 mg per intake, with a maximum of 40 mg daily. You’re not supposed to take it after 6 p.m. because it can cause high blood pressure while lying down, leading to headaches or even stroke risk.
Midodrine isn’t new. It’s been used for decades in patients with Parkinson’s, diabetes, and spinal cord injuries. But its use in MS is growing - not because it fixes the disease, but because it fixes a symptom that makes daily life unbearable.
Why MS Patients Struggle with Low Blood Pressure
Multiple sclerosis damages the autonomic nervous system - the part of your nerves that controls things you don’t think about: heart rate, digestion, and blood pressure regulation. When signals from the brain to the blood vessels get scrambled, standing up doesn’t trigger the normal tightening of vessels needed to keep blood flowing to the brain.
Studies show that up to 50% of people with progressive MS experience orthostatic hypotension. For some, it’s mild - just a momentary lightheadedness. For others, it’s constant. One patient described it as, “I stand up to get coffee, and the room spins. I sit back down. I try again. Same thing. I give up.”
Unlike fatigue or spasticity, low blood pressure doesn’t show up on MRIs. It’s invisible to most doctors unless you mention it. And many patients don’t realize it’s treatable.
How Midodrine Helps MS Patients
A 2023 study published in Neurology followed 68 MS patients with confirmed orthostatic hypotension. Half took midodrine; half took a placebo. After six weeks, those on midodrine saw a 22-point average increase in systolic blood pressure when standing. More importantly, 78% reported fewer dizzy spells and fewer falls.
One participant, a 52-year-old woman with secondary progressive MS, said she hadn’t been able to walk to her mailbox without sitting down halfway for a year. After starting midodrine, she started walking to the end of her driveway - and then to the corner store. “It wasn’t a miracle,” she said. “But it was the first time in years I didn’t feel like I was going to pass out every time I moved.”
Midodrine doesn’t improve muscle strength, balance, or cognition. It doesn’t slow MS progression. But it does restore a basic function: the ability to stand without fear.
Who Should Consider Midodrine?
Not everyone with MS needs midodrine. It’s only for those with documented orthostatic hypotension - meaning blood pressure drops by at least 20 mmHg systolic or 10 mmHg diastolic within three minutes of standing.
Doctors usually check this with a tilt-table test or a simple at-home test: measure blood pressure lying down, then again after standing for one minute and three minutes. If the drop is consistent and symptoms match, midodrine becomes a real option.
It’s also a good choice if:
- You’ve tried non-drug methods (increasing salt, drinking more water, wearing compression stockings) and they didn’t help enough
- You’re still active and want to regain mobility
- You’re not on other medications that raise blood pressure
It’s not for people with severe heart disease, uncontrolled high blood pressure, or urinary retention - common issues in advanced MS. Always talk to your neurologist or a specialist in autonomic disorders before starting.
Side Effects and Risks
Midodrine isn’t without downsides. The most common side effects are:
- Scalp tingling or itching (happens in about 1 in 4 users)
- Goosebumps
- Urinary urgency or difficulty emptying the bladder
- High blood pressure while lying down (supine hypertension)
Supine hypertension is the biggest risk. That’s why you never take midodrine after 6 p.m. and why you should sleep with your head slightly elevated. A 2022 study in Multiple Sclerosis Journal found that 17% of MS patients on midodrine had nighttime blood pressure above 160/95 - which increases stroke risk. That’s why regular home monitoring is critical.
Some patients report feeling “wired” or anxious. If that happens, the dose can be lowered. Most side effects fade within a week as the body adjusts.
Alternatives to Midodrine
Midodrine isn’t the only option. Other approaches include:
- Fludrocortisone: A steroid that helps the body hold onto salt and water. It’s cheaper but takes weeks to work and can cause swelling or low potassium.
- Pyridostigmine: Used for myasthenia gravis, it helps nerve signals reach blood vessels. Less effective for MS, but sometimes used when midodrine causes too many side effects.
- Compression garments: Waist-high compression stockings can help push blood back up. They’re free of side effects but can be uncomfortable in hot weather.
- Lifestyle tweaks: Drinking 16 oz of water before standing, avoiding hot showers, eating smaller meals, and rising slowly can help - but often not enough on their own.
Many patients use a combination: compression stockings + increased water + midodrine. This gives the best results with the lowest dose.
Real-Life Use: What Works in Practice
One neurologist in Minnesota tracks 120 MS patients on midodrine. Her rule: if a patient says, “I can’t stand up without feeling like I’m going to black out,” she starts them on 5 mg three times a day. After two weeks, she asks: “Can you get from your bed to the kitchen without sitting down?” If yes, they’re doing well. If not, she increases to 10 mg.
She also checks for supine hypertension with home monitors. Patients are told to record their blood pressure at 8 a.m., 1 p.m., 6 p.m., and right before bed. If nighttime readings are above 150/90, she cuts the evening dose or switches to fludrocortisone.
Most patients who stick with it for three months say their quality of life improves more than with any other MS treatment they’ve tried - not because they feel stronger, but because they feel safe.
When Not to Use Midodrine
Midodrine won’t help if your low blood pressure isn’t caused by autonomic failure. For example:
- If you’re dehydrated - fix that first
- If you’re on blood pressure meds that are too strong - adjust those
- If you have heart failure or severe arrhythmias - midodrine can make it worse
- If you’re pregnant or breastfeeding - it’s not studied enough to recommend
Also, don’t combine it with other vasoconstrictors like pseudoephedrine or certain migraine drugs. That can spike blood pressure dangerously.
Final Thoughts: Is It Worth It?
Midodrine doesn’t cure MS. It doesn’t repair nerve damage. But for many, it restores something just as important: control. Control over your body. Control over your day. Control over your dignity.
If you have MS and you’re constantly dizzy when you stand - don’t accept it as just part of the disease. Ask your doctor for a simple blood pressure test while standing. If the numbers drop and you feel it, midodrine might be the quiet, unglamorous treatment that changes your life.
It’s not for everyone. But for the right person, it’s the difference between staying in bed - and walking to the mailbox again.
Can midodrine help with MS fatigue?
No, midodrine doesn’t directly reduce MS fatigue. Fatigue in MS is caused by brain inflammation and nerve damage, not low blood pressure. However, if low blood pressure causes you to feel exhausted from constant dizziness or needing to sit down frequently, midodrine can reduce that secondary exhaustion by helping you stand and move without passing out. Many patients report feeling less tired overall - not because their MS fatigue improved, but because they’re not constantly recovering from fainting spells.
How long does it take for midodrine to start working?
Midodrine starts working within 30 to 60 minutes after taking it. Peak effects happen around 1 to 2 hours later, and the effect lasts about 3 to 4 hours. That’s why it’s taken three times a day - before breakfast, lunch, and mid-afternoon. You’ll know it’s working if you can stand up without dizziness or the need to sit back down within an hour of taking the dose.
Is midodrine safe for long-term use in MS patients?
Yes, midodrine is generally safe for long-term use if monitored properly. Studies show patients have used it for over five years without major organ damage. The main risks are supine hypertension and urinary issues, both of which can be managed with dose timing and regular blood pressure checks. There’s no evidence it worsens MS progression or causes nerve damage. The biggest challenge is adherence - many stop because of scalp itching or the need to time doses around meals.
Can I take midodrine with my other MS medications?
Midodrine usually works well with common MS drugs like interferons, glatiramer acetate, or S1P modulators. But it can interact with other medications that raise blood pressure, such as decongestants (pseudoephedrine), certain antidepressants (SNRIs), and migraine drugs like triptans. Always give your pharmacist a full list of everything you take - including over-the-counter meds and supplements. They can flag potential interactions.
Do I need to get blood tests while taking midodrine?
No routine blood tests are required for midodrine. Unlike some other blood pressure drugs, it doesn’t affect kidney or liver function. However, your doctor may check your blood pressure at home or during visits to make sure you’re not getting too high when lying down. If you have other conditions like diabetes or heart disease, you may need additional monitoring - but not because of midodrine itself.
What happens if I miss a dose of midodrine?
If you miss a dose, take it as soon as you remember - but only if it’s still before 6 p.m. If it’s later than that, skip it. Don’t double up. Missing one dose won’t cause withdrawal, but you may feel dizzy again when standing. That’s normal. The effect fades quickly. Just wait until your next scheduled dose. Consistency matters more than perfection - aim to take it at the same times each day.
Can midodrine cause weight gain?
Midodrine itself doesn’t cause weight gain. But some patients report feeling less dizzy and more active after starting it, which can lead to increased appetite. Others may retain fluid if they combine midodrine with fludrocortisone or eat more salt to help with blood pressure. If you notice sudden weight gain (more than 3 pounds in a week), check your blood pressure and talk to your doctor - it could mean you’re retaining fluid or your dose is too high.