What is the appropriate workup for a 51-year-old male with hypertension (HTN), taking lisinopril (angiotensin-converting enzyme inhibitor) and hydrochlorothiazide (HCTZ, diuretic), who experiences recurrent severe headaches, dry cough, neck pain, and tinnitus, with a history of previously taking amlodipine (calcium channel blocker)?

From the Guidelines

This patient should be sent to the emergency room for immediate evaluation due to the severity of symptoms and potential risk of a neurological emergency. The combination of new-onset severe headaches, neck pain, and a dry cough after switching from amlodipine to lisinopril-HCTZ raises several concerns. The ACE inhibitor lisinopril is likely causing the dry cough as this is a common side effect 1. More concerning, however, are the severe headaches which could indicate a serious vascular condition such as subarachnoid hemorrhage, arterial dissection, or reversible cerebral vasoconstriction syndrome. The patient's hypertension is a risk factor for these conditions. Emergency evaluation should include:

• Neuroimaging (CT or MRI of the brain)
• Possibly vascular studies (CT angiography or MR angiography)
• Blood pressure assessment While in the ER, the patient's antihypertensive medication should be reconsidered - switching back to amlodipine or another non-ACE inhibitor may be appropriate to address both the cough and better control blood pressure, as recommended by the seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure 1. The American College of Physicians and American Academy of Family Physicians joint guideline on pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets also supports the consideration of treatment goals based on individual patient risk factors and benefits 1. Additionally, the patient's tinnitus should be evaluated according to the ACR Appropriateness Criteria for tinnitus, which recommends a targeted history and clinical examination as the initial evaluation, and consideration of imaging studies based on the type of tinnitus and associated symptoms 1. These symptoms require urgent assessment as they could represent a neurological emergency, particularly given the temporal pattern, severity, and association with physical exertion.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient Presentation

The patient is a 51-year-old male with hypertension, taking lisinopril and hydrochlorothiazide, who experiences recurrent severe headaches, dry cough, neck pain, and tinnitus. He has a history of previously taking amlodipine.

Differential Diagnosis

• Primary headache disorders, such as migraine or tension-type headache 2
• Secondary headache disorders, such as those caused by vascular, neoplastic, infectious, or intracranial pressure/volume causes 2
• Angiotensin-converting enzyme inhibitor (ACEI)-associated cough, given the patient's history of taking lisinopril 3

Evaluation and Triage

• The patient should be evaluated to determine whether their headache is most likely a primary or a secondary headache disorder 2
• The patient's symptoms, such as dry cough and neck pain, should be considered in the evaluation 2, 3
• A triage system, such as the Manchester Triage System (MTS) or Emergency Severity Index (ESI), can be used to prioritize the patient's care 4, 5
• The patient's illness severity can be triaged into 5 levels of acuity based on physiological abnormalities, such as those in need of Resuscitation, Emergent care, Urgent care, Less urgent and Non-urgent care 5

Potential Causes of Symptoms

• The patient's dry cough may be related to the use of lisinopril, an ACEI, which is known to cause cough in some patients 3
• The patient's headaches may be related to their hypertension or other underlying medical conditions 2
• The patient's neck pain and tinnitus may be related to their headaches or other underlying medical conditions 2

Next Steps

• Further evaluation and testing, such as imaging studies or laboratory tests, may be necessary to determine the cause of the patient's symptoms 2, 6
• The patient's medication regimen may need to be adjusted or changed, such as switching from lisinopril to a different antihypertensive medication 3
• The patient should be monitored closely for any changes in their symptoms or condition, and triaged accordingly 4, 5