What is the best treatment approach for a patient with hypertension, chronic otitis media, and headache?

Management of Hypertension, Chronic Otitis Media, and Headache

This patient requires immediate initiation of antihypertensive therapy with an ACE inhibitor or ARB as first-line treatment for her uncontrolled hypertension (BP readings 161-171/95-110), while continuing antibiotic therapy for her chronic otitis media and addressing her headache which may be related to either condition. 1, 2

Hypertension Management

Assessment

• Current BP readings (161-171/95-110) confirm uncontrolled hypertension requiring prompt intervention
• History of hypertension during pregnancies suggests underlying predisposition
• No contraindications to antihypertensive therapy noted

Treatment Plan

1. First-line pharmacotherapy:

   • Start with an ACE inhibitor (e.g., lisinopril 10mg daily) or ARB 1, 3
   • Lisinopril has demonstrated superior reductions in systolic and diastolic BP compared to hydrochlorothiazide 3
   • Target BP <130/80 mmHg 1

2. Monitoring and follow-up:

   • Schedule follow-up within 1-2 weeks due to BP ≥160/100 mmHg 2
   • Monitor serum creatinine, eGFR, and potassium within 2-4 weeks of starting ACE inhibitor/ARB 2
   • Implement home BP monitoring to document response to treatment 2

3. Lifestyle modifications:

   • DASH-style eating pattern with reduced sodium (<2,300 mg/day)
   • Regular physical activity (150 minutes of moderate-intensity aerobic activity per week)
   • Weight management if applicable 2

Chronic Otitis Media Management

Assessment

• Currently on cephalexin 500mg TID for 10 days (started 28/09/2025)
• Right ear tympanic membrane dull with thick mucoid fluid effusion

Treatment Plan

1. Complete current antibiotic course as prescribed
2. Follow-up otoscopic examination after completion of antibiotics to assess response
3. Consider ENT referral if symptoms persist after antibiotic therapy, as chronic otitis media may require specialized management 4

Headache Management

Assessment

• Left-sided and posterior headache, throbbing in nature
• Improves when lying down
• Partially responsive to codeine
• No neurological deficits noted

Treatment Plan

1. Consider relationship to underlying conditions:

   • Headache may be secondary to hypertension - should improve with BP control 5
   • Could be related to chronic otitis media - may resolve with successful treatment of ear infection 6, 7

2. Symptomatic management:

   • NSAIDs (e.g., ibuprofen 400mg every 6-8 hours) for pain relief if not contraindicated
   • Avoid opioids for long-term management
   • Monitor for resolution with treatment of underlying conditions

3. Red flags requiring urgent assessment:

   • Worsening headache despite treatment
   • Development of neurological symptoms
   • Altered mental status
   • Signs of meningeal irritation 8

Integrated Approach

1. Prioritize hypertension control as this presents the most immediate cardiovascular risk
2. Complete antibiotic therapy for otitis media
3. Monitor headache response to both hypertension treatment and antibiotic therapy
4. Consider secondary causes of hypertension if BP remains difficult to control despite appropriate therapy 1

Common Pitfalls to Avoid

• Delayed treatment of severe hypertension increases risk of target organ damage
• Inadequate follow-up after initiating antihypertensive therapy
• Failing to recognize potential complications of chronic otitis media
• Missing secondary causes of headache that may require specific intervention
• Underestimating the importance of lifestyle modifications in hypertension management