You will be presented with the full text of a biomedical research paper. Please write an abstract for this paper. Your response should include the abstract and no additional text.

Paper text:
a 51-year - old woman presented with a 4-month history of presyncope and sometimes syncope on standing .
these episodes occurred with premonitory signs of nausea , lightheadedness , orthostatic visual blurring , and tachycardia .
she also complained of severe throbbing headache in the right occipitotemporal area preceded by photopsia , which was accompanied by vomiting , unilateral tinnitus , photophobia and phonophobia .
she had widespread body pain , chronic fatigue , muscle tenderness , and difficulty sleeping .
examination between the attacks revealed a blood pressure ( bp ) of 120/70 mmhg , regular pulse at 76 bpm , no carotid or supraclavicular bruits , and no cardiac murmurs .
her physical examination was normal except for 13 specific points of tenderness on palpation ; left and right occiput , trapezius , supraspinatus muscles , lower cervical spaces , second ribs , knees , and left lateral epicondyle .
blood tests including electrolyte , epinephrine and norepinephrine , thyroid function test , venereal disease research laboratory ( vdrl ) test , hiv , rheumatoid factor , lupus anticoagulant , antiphospholipid antibody , antinuclear antibody , antineutrophil cytoplasmic antibody , and anti - ro / la antibody were unremarkable .
24-hour holter monitoring , an echocardiogram , an electroencephalogram , and brain ct angiogram were normal .
bp and hr responses during lying to standing were characterized by increase in hr from 78 to 135 bpm without a significant decrease of bp ( fig .
was decreased to 5.04 bpm ( normal > 12 bpm ) and the expiration - to - inspiration ( e : i ) ratio was within normal range . during valsalva maneuver ,
the sympathetic skin response ( ssr ) was unremarkable . on the head - up tilt table test ( hutt ) at 70 for 30 minutes ,
changes in systolic bp , diastolic bp , and hr were calculated with respect to basal values .
very low dose isoproterenol ( 2 g ) infusion test demonstrated excessive tachycardia of hr increment of 49 bpm without a significant decrease of bp ( fig .
hutt was interrupted because of the patient 's intense malaise , lightheadedness , and palpitations as she recognized these symptoms as prodromes of her episodes of transient loss of consciousness .
the patient has been treated with topiramate , antidepressants and antiepileptic gabaergic drugs with gradual improvement of the headache and widespread pain over one month .
she was subsequently treated with midodrine and fludrocortisone and advised to increase salt and fluid intake .
application of an abdominal binder , aerobic exercise and physical counter - maneuvers   were recommended to help with autonomic conditioning .
they resulted in a reduction of supine and erect hr to 76 and 92 bpm , respectively , along with symptomatic improvement over 2 months ( fig .
the active standing test and hutt with an isoproterenol challenge of this patient identified pots and evidence of sympathetic -adrenergic supersensitivity .
the hr variance analysis also showed that the patient had a reduced vagally mediated variability in hr .
pathogenesis of pots is heterogenous and may include sympathetic hyperactivity with peripheral denervation , hypovolemia , and physical deconditioning
. the evaluation should include an electrocardiogram or 24-hour holter monitoring to exclude cardiac conduction abnormalities . both active standing tests and hutt
supine plasma norepinephrine concentrations are often elevated , suggesting hyperadrenergic state . however , our patient had normal range of norepinephrine and epinephrine level . we suppose that plasma norepinephrine may not reflect the central sympathetic activity .
pharmacologic agents including -blockers , midodrine , fludrocortisones , and octreotide have been used for the relief of symptoms .
increased sodium intake , elastic support hose , aerobic and resistance training exercise have been shown to be beneficial and should be encouraged .
patients who suffered from both migraine and fibromyalgia were older , and reported incapacitating headaches , more insomnia and mental stress , and lower quality of life .
the association between migraine , pots and vasovagal syncope was found in 0.18% of migraine .
the link between migraine and autonomic dysfunction is not clear , which may be explained by an imbalance between the sympathetic and parasympathetic systems .
autonomic abnormality in fibromyalgia explains the diverse clinical manifestations such as irritable bowel syndrome , sleep disorders , chronic fatigue , and sicca symptoms .
deconditioning of the muscles , consequence of pain related physical inactivity , is assumed to lead to autonomic dysfunction in fibromyalgia .
the coexistence of fibromyalgia and autonomic intolerance in migraine patients should be considered when choosing appropriate therapeutic measures .
we could not conclude whether the mental distress was caused by the fibromyalgia or migraine , or was an independent exacerbating factor for her symptoms .
we were unable to perform quantitative assessment of sudomotor function such as thermoregulatory sweat testing ( tst ) , quantitative sudomotor axon reflex testing ( qsart ) .
although these tests are very useful , they are not available except in highly specialized centers .
it should also be noted that transcranial doppler monitoring is valuable for evaluating changes in cerebral blood flow during hutt , although data in pots are inconsistent .
more precise information with quantitative sudomotor function and transcranial doppler analysis may be helpful for assessing and treating this patient . in conclusion ,
further studies are needed to demonstrate autonomic dysregulation in migraine with fibromyalgia , which may lead to diagnostic precision and effective clinical management .
postural orthostatic tachycardia syndrome ( pots ) refers to the presence of orthostatic intolerance with a heart rate ( hr ) increment of 30 beats per minute ( bpm ) or an absolute hr of 120 bpm or more . 
 there are sporadic reports of the autonomic nervous system dysfunction in migraine and fibromyalgia . 
 we report a case of pots associated with migraine and fibromyalgia . 
 the patient was managed with multidisciplinary therapies involving medication , education , and exercise which resulted in symptomatic improvement . 
 we also review the literature on the association between pots , migraine , and fibromyalgia .