What is the best course of action for a 15-year-old male patient presenting with dizziness for 2 days, with initial blood pressure (BP) reading of 133/77 and a current reading of 128/74, which is elevated for his age?

Management of Elevated Blood Pressure and Dizziness in a 15-Year-Old Male

This patient's blood pressure readings (133/77 and 128/74) fall into the elevated blood pressure category for adolescents, and the dizziness requires systematic evaluation before attributing it to blood pressure alone. 1

Blood Pressure Classification

For adolescents ≥13 years, the American Academy of Pediatrics defines:

• Normal BP: <120/80 mmHg 1
• Elevated BP: 120-129 mmHg systolic AND <80 mmHg diastolic 1
• Stage 1 Hypertension: 130-139/80-89 mmHg 2
• Stage 2 Hypertension: ≥140/90 mmHg 2

This patient's systolic readings (133 and 128 mmHg) place him in Stage 1 hypertension range, while his diastolic readings (<80 mmHg) are normal. 1, 2 When systolic and diastolic readings fall into different categories, the higher category determines classification. 2

Critical Next Steps

1. Confirm the Diagnosis

Do not diagnose hypertension based on two readings alone. A diagnosis of hypertension requires elevated readings on three separate occasions before establishing the diagnosis. 2 Blood pressure must be measured with the patient seated and relaxed using an appropriately sized cuff (bladder width 40% of mid-arm circumference, covering 80-100% of arm circumference). 2

2. Evaluate the Dizziness Systematically

The dizziness requires specific characterization before assuming it is BP-related. 3, 4

Key questions to determine dizziness type:

• Timing: Is it brief episodes with head movement (suggests BPPV) or persistent (suggests other causes)? 5
• Quality: True spinning vertigo, lightheadedness, near-fainting (presyncope), or imbalance? 3, 4
• Triggers: Position changes, specific head movements, or spontaneous? 3
• Associated symptoms: Hearing loss, tinnitus, neurologic deficits, or cardiac symptoms? 5

Essential physical examination components:

• Orthostatic vital signs: Measure BP and heart rate supine and after standing 1-3 minutes to assess for orthostatic hypotension (a drop ≥20 mmHg systolic or ≥10 mmHg diastolic). 3, 4
• Neurologic examination: Assess for focal deficits, cerebellar signs, or cranial nerve abnormalities. 3
• Dix-Hallpike maneuver: If triggered by position changes, this tests for benign paroxysmal positional vertigo. 3, 4
• Cardiac examination: Assess for murmurs or arrhythmias. 3

3. Clinical Context Matters

The blood pressure readings of 128-133/74-77 mmHg are unlikely to cause dizziness in an adolescent. 1 Dizziness from hypertension typically occurs with severe hypertension (≥180/120 mmHg in adults, proportionally lower but still much higher in adolescents). 6 The 50th percentile for 14-year-old boys is approximately 118/73 mmHg, so this patient's readings are mildly elevated but not in a range that typically causes symptoms. 1

Common pitfalls to avoid:

• White coat hypertension is common in adolescents and should be ruled out with ambulatory BP monitoring or home BP measurements. 2
• Anxiety can cause both elevated BP readings and dizziness, particularly in a school nurse's office setting. 7
• Do not aggressively treat BP numbers without confirming true hypertension and evaluating the dizziness separately. 7, 6

Recommended Management Algorithm

Immediate Actions:

1. Obtain a third BP measurement on a separate day, ensuring proper technique (seated, relaxed, appropriate cuff size). 2
2. Characterize the dizziness using the questions above and perform orthostatic vital signs. 3, 4
3. Perform targeted physical examination including neurologic assessment and Dix-Hallpike if indicated. 3

If BP Remains Elevated on Third Measurement:

1. Consider ambulatory BP monitoring to confirm hypertension and rule out white coat hypertension. 1, 2
2. Initiate lifestyle modifications as first-line intervention: dietary changes (reduce sodium, increase fruits/vegetables), regular physical activity, and weight management if overweight. 5, 2
3. Evaluate for secondary causes: Family history, medication use, sleep patterns, and consider basic labs (urinalysis, basic metabolic panel, lipid panel) if hypertension is confirmed. 5

For the Dizziness:

• If orthostatic hypotension is present: Address hydration, review medications, and consider increasing salt/fluid intake. 4
• If BPPV is diagnosed: Perform Epley maneuver (canalith repositioning). 3, 4
• If no clear cause is identified: Consider vestibular rehabilitation or reassurance if benign. 3

The treatment goal for confirmed hypertension in this adolescent is BP <130/80 mmHg, achieved initially through lifestyle modifications. 2 Pharmacologic treatment is reserved for confirmed hypertension that does not respond to lifestyle changes after 3-6 months or for Stage 2 hypertension with evidence of target organ damage. 5