What should I do for dizziness, headache, and blood pressure (bp) of 160/100?

Management of Blood Pressure 160/100 mmHg with Dizziness and Headache

You need to immediately confirm this blood pressure reading and exclude a hypertensive emergency, then initiate both lifestyle modifications and pharmacological treatment without delay. 1

Immediate Assessment Required

First, rule out hypertensive emergency by assessing for acute target organ damage. Your patient's symptoms of dizziness and headache warrant urgent evaluation, as these could represent hypertensive encephalopathy or other serious complications. 1, 2

Critical Red Flags to Assess Now:

• Neurological symptoms: Altered mental status, seizures, visual changes beyond mild blurriness, severe unrelenting headache 2, 3
• Cardiovascular symptoms: Chest pain, severe dyspnea, signs of acute heart failure 2, 3
• Fundoscopic examination: Look for papilledema, hemorrhages, or exudates indicating malignant hypertension 1, 2
• Renal function: Check for acute kidney injury 2

If BP ≥180/110 mmHg or any acute organ damage is present, this is a hypertensive emergency requiring immediate hospitalization and IV antihypertensive therapy. 1 However, your patient at 160/100 mmHg with non-specific symptoms likely represents Grade 2 hypertension without emergency features. 1

Confirmation of Diagnosis

Confirm the BP reading of 160/100 mmHg as soon as possible (within 1 month) using either home blood pressure monitoring or 24-hour ambulatory monitoring. 1 At the initial visit, take three BP measurements 1-2 minutes apart and use the average of the last two readings. 1

• If out-of-office monitoring is not feasible, confirm with repeated office measurements on 2-3 separate visits 1
• Home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg confirms hypertension 1

Immediate Treatment Strategy

Start drug treatment immediately along with lifestyle interventions—do not wait for lifestyle modifications alone. 1, 4 A BP of 160/100 mmHg is classified as Grade 2 hypertension, which mandates prompt pharmacological therapy. 1, 5

Pharmacological Treatment

Initiate two-drug combination therapy immediately rather than monotherapy, as most patients with Grade 2 hypertension require multiple agents to achieve control. 1, 5

For non-Black patients, start with:

• ACE inhibitor (e.g., lisinopril 10 mg daily) OR ARB PLUS
• Dihydropyridine calcium channel blocker (e.g., amlodipine 5 mg daily) OR thiazide-like diuretic (e.g., chlorthalidone 12.5-25 mg daily) 1, 5, 6, 7

For Black patients, start with:

• ARB PLUS dihydropyridine calcium channel blocker OR thiazide-like diuretic 1, 5

Use single-pill combination formulations whenever possible to improve adherence. 5

Dose Titration Algorithm:

1. Week 0: Start low-dose two-drug combination 5
2. Month 1: Reassess BP; if not at goal, increase to full doses of both medications 1, 5
3. Month 2-3: If still uncontrolled, add a third agent (complete the triple therapy of ACE-I/ARB + CCB + thiazide-like diuretic) 1, 5
4. If resistant: Add spironolactone 25 mg daily, or if contraindicated, consider amiloride, doxazosin, or beta-blocker 1

Blood Pressure Goals

Target BP <130/80 mmHg for most adults, achieved within 3 months of treatment initiation. 1, 4, 5 Aim to reduce BP by at least 20/10 mmHg from baseline. 1, 4

For adults <65 years, a systolic BP of 120-129 mmHg is optimal if well tolerated. 5

Lifestyle Modifications (Start Immediately)

Implement these evidence-based interventions alongside pharmacotherapy: 1, 5

• Sodium restriction: Reduce intake to <2,300 mg/day (approximately 5g salt/day) 1, 8
• DASH or Mediterranean diet: 8-10 servings of fruits/vegetables daily, low-fat dairy, fish, nuts, olive oil 1, 5
• Weight management: Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1, 5
• Physical activity: 150 minutes/week of moderate-intensity aerobic exercise PLUS resistance training 2-3 times/week 1, 5
• Alcohol limitation: <100g/week of pure alcohol (approximately 2 drinks/day for men, 1 drink/day for women) 1
• Smoking cessation if applicable 5

Monitoring Plan

• Reassess BP within 1 month after initiating therapy to evaluate response 1, 5
• Achieve target BP within 3 months of treatment initiation 1, 5
• Monitor serum creatinine, eGFR, and potassium at least annually, or more frequently if on ACE-I/ARB/diuretic 1
• Obtain baseline 12-lead ECG to assess for left ventricular hypertrophy 1
• Consider home BP monitoring to confirm office readings and assess treatment response 1

Addressing the Symptoms

The dizziness and headache are likely related to the elevated BP itself, but require careful evaluation. 1, 9 These non-specific symptoms are common in hypertensive urgency (severe BP elevation without acute organ damage). 3, 9

Do NOT rapidly lower BP in this setting—gradual reduction over days to weeks is appropriate for asymptomatic or mildly symptomatic severe hypertension. 9 Aggressive acute lowering can cause hypoperfusion and worsen symptoms. 3, 9

Reassess symptoms after 24-48 hours of treatment—if headache worsens, becomes severe and unrelenting, or if new neurological symptoms develop, this warrants immediate re-evaluation for hypertensive emergency. 2, 3

Common Pitfalls to Avoid

• Therapeutic inertia: Failing to initiate or intensify treatment promptly is a major cause of poor BP control 4
• Inadequate dosing: Use full doses of medications before adding additional agents 5
• Ignoring medication adherence: Address cost, side effects, and complexity of regimen 1, 4
• Overly aggressive acute lowering: In the absence of true emergency, rapid BP reduction can cause harm 3, 9
• Using inappropriate agents: Avoid sublingual nifedipine, which causes unpredictable and potentially dangerous BP drops 10

Secondary Hypertension Screening

Consider screening for secondary causes if: 1, 5

• Age <40 years with new-onset hypertension
• Resistant hypertension (uncontrolled on 3+ drugs)
• Sudden worsening of previously controlled hypertension
• Suggestive symptoms (muscle weakness, palpitations, sweating suggesting endocrine causes)

Obtain serum creatinine, eGFR, urine albumin-to-creatinine ratio, and electrolytes as baseline testing. 1