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Behind a cold sweat is the sympathetic nervous system, the body's "stress nerve". It releases adrenaline, narrows the blood vessels in the skin so that the heart and brain get enough blood, and at the same time activates the sweat glands. The result is the typical pale, cool, clammy skin. This is different from warm sweating in the heat or during exertion (more under excessive sweating), drenching sweats at night (night sweats) and hot flushes, after which many people briefly feel chilly.
A cold sweat is one of the classic accompanying signs of a heart attack. With severe chest pressure, the picture is clear. It is overlooked when the pain is absent or atypical: women more often experience shortness of breath, nausea, pain in the upper abdomen, back or jaw, and unusual weakness. In people with long-standing diabetes, nerve damage can dampen the pain; older people sometimes simply seem confused or exhausted. A sudden cold sweat with nausea or breathlessness is then often the clearest sign. Many people wait too long because they are "only" sweating. How to make sense of stabbing chest symptoms is described in the article on stabbing chest pain.
If blood sugar falls too far, the body sounds the alarm: sweating, trembling, palpitations, ravenous hunger and inner restlessness. If the brain gets too little sugar, difficulty concentrating, confusion, slurred speech, behaviour as if drunk and, in extreme cases, seizures or unconsciousness follow. A hypo is generally defined as a value below 70 mg/dl (3.9 mmol/l).
Those affected are almost exclusively people with diabetes who take medicines that lower blood sugar regardless of its current level — insulin, sulfonylureas such as glimepiride, or glinides. Metformin, gliptins or SGLT2 inhibitors on their own rarely cause hypos. Typical triggers are skipped meals, unaccustomed exercise, alcohol, declining kidney function or weight loss while the dose stays the same. Hypos at night often show themselves indirectly through nightmares, sweat-soaked bedding and headaches in the morning.
The most common harmless cause is the vasovagal reaction: after standing for a long time, in the heat, with pain, at the sight of blood or with great agitation, the pulse and blood pressure drop briefly. Beforehand there are typically a cold sweat, pallor, nausea, yawning, ringing in the ears and vision going black. If you lie down in time and raise your legs, you usually recover within minutes. More on this under fainting and low blood pressure. If it all happens when you get up, blood pressure lowered too far by medicines may also be the cause.
Severe pain triggers the same stress reaction: kidney and gallstone colic, an acute abdomen or an injury often come with a cold sweat, restlessness and vomiting. Intense nausea — before vomiting, with a migraine or with travel sickness — also often brings on a cold sweat. This is not a condition in its own right, but an indication of how great the strain is. Persistent severe abdominal pain should be assessed by a doctor promptly, and if it keeps getting worse, in the emergency department.
During a panic attack, adrenaline floods the body: a cold sweat, a racing heart, trembling, breathlessness, tingling and a fear of dying peak within a few minutes. The first time, this cannot be reliably told apart from a physical emergency from the outside — which is why having it checked is the right thing to do. If the attacks recur and the findings are normal, panic disorder is very treatable.
Cold, clammy, pale or mottled skin together with a fast, weak pulse, rapid breathing and confusion are signs of circulatory shock. Causes can be internal bleeding — from the stomach, for example, recognisable by black stools or vomiting blood, especially on blood thinners — a severe allergic reaction or blood poisoning (sepsis). With sepsis, there is usually also a fever or chills and an unusually severe feeling of being ill; at first the skin may also be warm. In all of these cases: call 112 immediately. The same applies to a cold sweat with sudden shortness of breath, as occurs with a pulmonary embolism, or with a very fast or very slow pulse.
In alcohol withdrawal, sweating, trembling, restlessness and a racing heart are among the first signs; without medical support, seizures and delirium can follow. If you drink heavily on a regular basis and want to stop, you should do so with medical support — more under alcohol dependence. Withdrawal from opioids or sedatives also makes you sweaty. With heat exhaustion, the skin is likewise cool, pale and wet, together with weakness, headache and nausea. If someone becomes confused or their body temperature rises sharply, heatstroke is imminent — an emergency.
Attacks of sweating, headache, a racing heart and greatly raised blood pressure can, rarely, point to a hormone-producing tumour of the adrenal gland (phaeochromocytoma). An overactive thyroid, by contrast, tends to cause warm, persistent sweating.
These checks only make sense if there are no warning signs, and they do not replace a diagnosis. They help you make sense of the situation and describe it precisely later on.
With recurring cold sweats, it is worth taking a close look at your medication plan — the timing often fits strikingly well with when you take your medicines.
They lower blood sugar regardless of how high it is at the moment, and can therefore lower it too far. The risk increases when meals are missed, with unaccustomed exercise, with declining kidney function and in older age. Alcohol inhibits the release of sugar from the liver — a hypo can then occur hours later, even the next morning. Some antibiotics, such as co-trimoxazole, can increase the blood sugar-lowering effect of sulfonylureas.
Beta blockers such as bisoprolol or metoprolol dampen trembling and palpitations — two important warning signs of a hypo. Sweating is controlled via a different nerve pathway and is often preserved. For people with diabetes on beta blockers, a cold sweat can therefore be the only clear signal. That is no reason to stop the beta blocker, but it is a reason always to measure your blood sugar when you sweat.
If blood pressure is lowered too far, dizziness, vision going black and a cold sweat develop — typically after starting or increasing the dose, in the heat, with diarrhoea or when you are not drinking enough. The combination of nitrates with erection medicines such as sildenafil or tadalafil is dangerous: it can trigger a life-threatening drop in blood pressure and is therefore not allowed.
Strong painkillers such as tramadol or tilidine frequently cause sweating; after longer use, stopping abruptly leads to withdrawal symptoms with sweating attacks, restlessness, goosebumps and diarrhoea. Antidepressants such as sertraline, venlafaxine or duloxetine also often increase sweating, and stopping them abruptly can likewise trigger sweating, dizziness and restlessness — more in the guide Stopping SSRIs. More serious is serotonin syndrome: if serotonergic medicines are combined, for example an antidepressant with tramadol, triptans, St John's wort or certain other active substances, sweating, restlessness, trembling, muscle twitching, diarrhoea, a racing heart and fever can occur. This needs to be assessed by a doctor straight away, and with severe signs via 112.
When a fever comes down on paracetamol, ibuprofen or metamizole, the body sweats off heat — that is to be expected. According to the package leaflet, over-the-counter pain and fever medicines should only be taken for a few days without medical advice, usually no longer than three to four days in a row; if the fever persists, the cause needs to be clarified. On metamizole, fever, a sore throat and inflammation of the lining of the mouth are a warning signal for a rare drop in white blood cells and must be assessed by a doctor immediately.
Dose reminders and your history show whether dose, meals and time of day fit together.
The digital medication plan shows the emergency services and your practice all active substances and doses at once.
This article is for general information and does not replace medical advice, diagnosis or treatment. The self-checks described are a guide and not a diagnosis. If you have a cold sweat with chest pressure, shortness of breath, nausea, confusion or reduced consciousness, signs of shock, or a hypo that does not improve quickly, please contact the emergency services on 112 immediately.
