Objective: To compare the frequency and clinical aspects of coat-hanger ache (CHA) in patients with orthostatic hypotension (OH) (SBP↓ >20 mmHg within 3 minutes of standing) during daily activities versus during head-up tilt (HUT). Background Questionnaires administered to OH patients reveal frequent CHA occurrence (∼90%), but its precipitation during HUT has not been investigated. Design/Methods: Retrospective IRB-approved review of prospectively collected data on 18 dysautonomic patients. Heart rate response to deep breathing (HRDB), Valsalva maneuver (VM), HUT, and thermoregulatory sweat test (TST) evaluated cardiovagal, adrenergic, and sudomotor functions. Occurrence and clinical features of CHA during daily activities and during HUT were recorded. Data were analyzed with descriptive statistics and expressed as mean ± SE. Results: Nine of 18 patients reported precipitation of dull ache or pressure affecting the posterolateral neck and shoulders within 3-10 minutes of standing or after a variable duration of sitting that was relieved within 5-20 minutes of recumbency. During HUT, 3/9 patients developed CHA. The other nine patients were without CHA during daily activities or during HUT. One of three patients who developed CHA during HUT reported amelioration during presyncopal phase. All patients had OH with SBP↓ 57.05 ± 6.02 within 1 minute of HUT. HUT duration tolerated was 5.28 ± 0.83 minutes. Autonomic tests demonstrated severe adrenergic (OH), cardiovagal (HRDB 3.07 ± 0.48 [normal, ≥ 11 bpm] and VR 1.22 ± 0.05 [normal, 1.76 ± 0.03]), and sudomotor (partial or complete anhidrosis) impairment. Conclusions: CHA was reported by 50% of OH patients during daily activities and by only 16.7% during HUT. These observations suggest a lack of direct association between OH and CHA and a complex pathophysiology. Disclosure: Dr. Khurana has nothing to disclose.