What is the appropriate management for a patient with hypertension and paresthesia in the head?

Management of Hypertension with Head Paresthesia

This patient requires immediate evaluation to rule out serious neurological causes of head paresthesia, while simultaneously optimizing blood pressure control with oral antihypertensive therapy targeting systolic BP of 120-129 mmHg.

Immediate Assessment Priority

The combination of hypertension and head paresthesia demands urgent neurological evaluation, as paresthesias can indicate:

• Intracranial hypertension - Head paresthesias occur in 22% of patients with benign intracranial hypertension and resolve promptly when intracranial pressure is lowered 1
• Carotid or vertebral artery dissection - Particularly in younger patients presenting with acute paresthesias followed by neurological symptoms 2
• Structural lesions - Cavernous sinus processes, carotid artery aneurysms, or other lesions affecting cranial nerves can present with facial pain and paresthesias 3

Critical Red Flags Requiring Emergency Evaluation

• Papilledema on fundoscopic examination (indicates elevated intracranial pressure) 3
• Other cranial neuropathies, motor weakness, or vision changes 3
• Sudden onset of symptoms, especially with neck or scalp pain 3, 2
• Meningeal signs such as stiff neck with headache 3

Blood Pressure Management Approach

Target Blood Pressure

Aim for systolic BP of 120-129 mmHg through gradual reduction over 24-48 hours 4. Avoid aggressive BP lowering, which can precipitate cerebral ischemia 4.

Medication Strategy

The European Society of Cardiology recommends combination therapy with:

• RAS blocker (ACE inhibitor or ARB) - such as lisinopril 5
• Calcium channel blocker - such as amlodipine 6
• Thiazide/thiazide-like diuretic or beta-blocker 7, 4

If already on three-drug therapy and BP remains uncontrolled, add low-dose spironolactone (25 mg daily) as fourth-line agent if serum potassium <4.5 mmol/L and eGFR >45 ml/min/1.73m² 7.

Monitoring Requirements

• Check serum potassium and renal function 1-2 weeks after medication changes 7
• Monitor for orthostatic hypotension with multiple antihypertensive agents 7
• Verify medication adherence and proper BP measurement technique 7
• Consider home or ambulatory BP monitoring to rule out white coat hypertension 7, 4

Neurological Workup Algorithm

For Elderly Patients with Vascular Risk Factors

In elderly patients with hypertension, hyperlipidemia, or diabetes without temporal tenderness, jaw claudication, or scalp pain 3:

• Measure blood pressure, serum glucose, and hemoglobin A1c 3
• Perform fundoscopic examination for papilledema 3
• Arrange follow-up to determine if symptoms spontaneously resolve 3
• If no improvement, obtain MRI brain with contrast and MRI whole spine 3

For Elderly Patients with Concerning Features

In elderly patients with scalp tenderness, jaw claudication, or pain 3:

• Check ESR and CRP immediately to evaluate for giant cell arteritis 3
• Perform temporal artery biopsy if results suggest arteritis 3
• Consult neuro-ophthalmology to facilitate biopsy and treatment 3

For Younger Patients or Those Without Vascular Risk Factors

Neuroimaging should be obtained in all young patients or those without compelling vasculopathic risk factors 3:

• MRI brain with contrast and MRI whole spine 3
• Look for neoplasm, demyelination, stroke, vascular abnormality, or infectious/inflammatory etiology 3
• Refer to neuro-ophthalmologist or neurologist 3

If Increased Intracranial Pressure Suspected

Evidence of papilledema, bilateral sixth nerve palsy, or meningeal signs requires 3:

• Neuroimaging first, then lumbar puncture to measure intracranial pressure 3
• Evaluate for meningitis (infectious, inflammatory, carcinomatous) or demyelination 3
• Systemic serology including Lyme and syphilis testing 3

Common Pitfalls to Avoid

• Never combine two RAS blockers (ACE inhibitor + ARB), as this increases adverse effects without benefit 7
• Avoid aggressive BP reduction in the setting of neurological symptoms, as this can worsen cerebral ischemia 4
• Do not use short-acting nifedipine for hypertensive urgency due to risk of precipitous BP drops 4
• Be cautious with centrally acting agents like clonidine in patients with neurological symptoms 7
• Never ignore fundoscopic examination - papilledema indicates elevated intracranial pressure requiring urgent intervention 3

Lifestyle Modifications

While optimizing medical therapy 3:

• Weight reduction to ideal body weight 3
• Regular dynamic exercise (brisk walking) 3
• Limit alcohol to <21 units/week (men) or <14 units/week (women) 3
• Reduce dietary sodium 3
• Increase fruit and vegetable consumption 3
• Smoking cessation 3