What is the approach to managing vertigo, dizziness, nausea, vomiting, and abdominal pain in a 56-year-old female patient with a history of Hypertension (HTN)?

Approach to Vertigo, Dizziness, Nausea/Vomiting, and Abdominal Pain in a 56-Year-Old Female with Hypertension

This constellation of symptoms in a hypertensive patient requires immediate assessment for hypertensive emergency, as dizziness and gastrointestinal complaints (abdominal pain, nausea) are recognized manifestations of impaired cerebral autoregulation and acute hypertension-mediated organ damage. 1

Initial Risk Stratification: Emergency vs. Urgency

The critical first step is determining whether acute hypertension-mediated organ damage is present, not simply measuring the absolute blood pressure value. 1, 2

Immediate Blood Pressure Assessment

• Measure BP in both arms and at the lower limb to detect pressure differences from aortic dissection 1
• Perform repeated measurements over time, as BP often falls considerably without medication 1
• If BP >180/120 mmHg with organ damage = hypertensive emergency; without organ damage = hypertensive urgency 3

Key Historical Elements to Obtain

• Emergency symptoms: headache, visual disturbances, chest pain, dyspnea, focal neurological symptoms 1
• Medication adherence: non-adherence, recent withdrawal of antihypertensives 1
• Precipitating drugs: NSAIDs, steroids, cyclosporin, sympathomimetics, cocaine 1
• Pre-existing hypertension: duration, previous BP control, current treatment 1

Diagnostic Workup

Mandatory Laboratory Analysis

1, 2

• Hemoglobin, platelet count
• Creatinine, sodium, potassium
• LDH, haptoglobin (to assess for thrombotic microangiopathy)
• Quantitative urinalysis for protein, urine sediment for erythrocytes, leukocytes, cylinders

Essential Diagnostic Examinations

1

• ECG (ischemia, arrhythmias, left ventricular hypertrophy)
• Fundoscopy (if malignant hypertension suspected)

Additional Studies Based on Presentation

1, 2

• Troponin if chest pain present
• CT brain if focal neurological signs or altered mental status
• Chest X-ray or point-of-care ultrasound if dyspnea present
• Transthoracic echocardiography for cardiac structure/function assessment

Management Algorithm

If Hypertensive Emergency (Organ Damage Present)

Target: Reduce mean arterial pressure (MAP) by 20-25% over the first hour, then to 160/110-100 mmHg over next 2-6 hours 1, 3

• Initiate intravenous antihypertensive therapy immediately 1
• Avoid rapid BP lowering beyond these targets to prevent cardiovascular complications 1
• Admit to intensive care unit for continuous monitoring 3

If Hypertensive Urgency (No Organ Damage)

Target: Gradual BP lowering over 24-48 hours with oral medication 1, 3

• Do NOT use short-acting nifedipine due to rapid BP fall risk 1
• Oral BP-lowering medication or adaptation of current regimen 1
• Avoid aggressive BP lowering 3
• Outpatient follow-up acceptable if reliable 3

If Medication-Induced Orthostatic Hypotension

Dizziness in hypertensive patients is frequently unrelated to elevated BP but rather due to hypotension after intake of antihypertensive drugs. 4

• Perform lying-to-standing BP test 2
• Review and reduce offending medications (beta-blockers, calcium channel blockers) 2
• Gradual dose reduction over 1-2 weeks 2
• Patient education on non-pharmacologic measures 2

Symptomatic Management of Nausea/Vomiting

First-Line Antiemetic Therapy

• Metoclopramide 10 mg IV/IM for acute nausea/vomiting 5
• Ondansetron 4-8 mg IV as alternative 5-HT3 antagonist 6

Important Metoclopramide Precautions

5

• Maximum duration: 12 weeks to minimize tardive dyskinesia risk
• Contraindicated if: GI bleeding/obstruction, pheochromocytoma, seizure disorder
• Monitor for extrapyramidal symptoms (occur in 1 in 500 patients, more common in patients <30 years)
• Use cautiously with depression history

If Initial Antiemetics Fail

• Consider palonosetron (longer half-life 5-HT3 antagonist) if ondansetron ineffective 6
• Optimize underlying hypertension management 6

Critical Pitfalls to Avoid

Common Misdiagnosis

78% of patients hospitalized with "hypertensive crisis" actually have other conditions (tension headaches, stroke, Meniere's disease) that present with hypertension but are not caused by it. 4

Vertigo-Specific Considerations

• Vertigo occurs in 20% of hypertensive patients but is unrelated to elevated BP 4
• More commonly due to: peripheral vestibular disease, neurological conditions, or post-medication hypotension 4
• Consider Meniere's disease, benign positional vertigo, or vestibular neuritis as alternative diagnoses 4

Abdominal Pain Red Flags

While abdominal pain can be a non-specific symptom of hypertensive emergency 1, also consider:

• Aortic dissection (requires CT-angiography of thorax/abdomen) 1
• Acute coronary syndrome with atypical presentation
• Renal infarction or acute kidney injury

Medication Reconciliation

• Verify patient is not taking multiple metoclopramide formulations simultaneously (tablets, ODT, oral solution, injection) 5
• Assess for drug interactions: MAOIs, insulin (may require dose adjustment), sedatives 5