What is the next step in evaluating a 40-year-old overweight white female with a history of controlled hypertension on metoprolol (beta blocker) and another antihypertensive medication, and a prediabetic condition, who presents with daily symptoms of intense head pressure, pain, dizziness, imbalance, blurry vision, plugged ears, and ear pressure, despite a clear stroke computed tomography (CT) scan and normal blood pressure, which started at the age of 38?

Comprehensive Neurological and Vestibular Evaluation is the Next Step

Given your persistent daily symptoms of head pressure, dizziness, imbalance, blurry vision, and ear symptoms despite controlled blood pressure and a clear stroke CT, you need a thorough neurological and vestibular workup to identify the underlying cause, with particular attention to potential medication side effects from metoprolol and evaluation for secondary causes of your symptoms.

Immediate Diagnostic Priorities

1. Comprehensive Neurological Assessment

Your constellation of symptoms—head pressure, dizziness, imbalance, blurry vision, and altered mental status—requires systematic evaluation for several potential causes 1:

• Complete neurological examination focusing on mental status changes, visual disturbances, gait abnormalities, and cranial nerve function 1
• Fundoscopic examination to assess for papilledema, retinal hemorrhages, or cotton wool spots that would indicate hypertensive retinopathy or elevated intracranial pressure 1
• Visual acuity testing with assessment for afferent pupillary defect to screen for optic nerve pathology 1

2. Advanced Neuroimaging

While your initial stroke CT was clear, your persistent and progressive symptoms warrant more detailed imaging 1:

• MRI brain with and without contrast is superior to CT for detecting:

  • Posterior reversible encephalopathy syndrome (PRES), which can present with headache, visual disturbances, and altered mental status 1
  • Subtle ischemic changes not visible on CT 1
  • Secondary causes of intracranial hypertension 1
  • Chiari malformation, which can cause headache, dizziness, and imbalance 1

• MRI with FLAIR imaging specifically to evaluate for white matter lesions in posterior brain regions 1

• Coronal fat-saturated T2-weighted sequences to assess for dilated optic nerve sheaths if pseudotumor cerebri is suspected 1

3. Evaluate for Pseudotumor Cerebri (Idiopathic Intracranial Hypertension)

Your profile—overweight female in late 30s with headache, blurry vision, and dizziness—fits the classic presentation of pseudotumor cerebri 1:

• MRI findings to look for: empty sella, dilated optic sheaths, tortuous or enhancing optic nerves, flattening of posterior globes 1
• Lumbar puncture with opening pressure measurement if MRI shows no mass lesion or hydrocephalus 1
• This condition is rising in incidence parallel to the obesity epidemic and can cause severe headaches and visual impairments 1

Critical Medication Review: Metoprolol Side Effects

Your metoprolol (beta-blocker) may be contributing significantly to your symptoms and warrants immediate evaluation 2, 3:

Documented CNS Side Effects of Metoprolol

• Visual disturbances and blurred vision are well-documented side effects of metoprolol 2, 3
• Dizziness, lightheadedness, and confusion are among the most frequently reported CNS complications 3, 4
• Fatigue and sleep disturbances occur commonly with metoprolol therapy 3, 4
• Headache is a recognized adverse effect 4, 5

Why Metoprolol Causes These Symptoms

Beta-blockers, particularly lipophilic agents, cross the blood-brain barrier and cause CNS side effects 2, 3. While metoprolol is moderately lipophilic, elderly patients and those on chronic therapy are at higher risk for neurological symptoms 3.

Recommendation Regarding Metoprolol

Consider switching from metoprolol to a less CNS-penetrant beta-blocker (such as atenolol) or to an alternative antihypertensive class entirely 2. In documented case reports, patients with visual disturbances and neurological symptoms on metoprolol experienced complete resolution within 4 days of switching to atenolol 2.

Secondary Hypertension Workup

Given your young age at onset (38 years) and persistent symptoms despite treatment, evaluation for secondary causes is essential 1, 6:

Essential Laboratory Tests

• Serum electrolytes (sodium, potassium) to screen for primary aldosteronism 1
• Serum creatinine and eGFR to assess renal function 1
• Fasting glucose and lipid profile given your prediabetic condition 1
• Thyroid function tests as thyroid disease can cause hypertension and neurological symptoms 1
• Urinalysis with urine albumin-to-creatinine ratio to detect renal damage 1
• Serum aldosterone and plasma renin activity to evaluate for primary aldosteronism 6

Additional Investigations Based on Clinical Suspicion

• 24-hour ambulatory blood pressure monitoring to assess for masked hypertension or white coat effect 1
• Sleep study if you have snoring or daytime sleepiness, as obstructive sleep apnea is a common secondary cause 1
• Renal artery imaging (ultrasound with Doppler or MR angiography) if renal artery stenosis is suspected 1

Vestibular and Otologic Evaluation

Your symptoms of dizziness, imbalance, plugged ears, and ear pressure require specific vestibular assessment:

• Audiometry and tympanometry to evaluate for Eustachian tube dysfunction or middle ear pathology
• Vestibular function testing if peripheral vestibular disorder is suspected
• ENT consultation for persistent ear symptoms

Cardiovascular Assessment

Given your controlled hypertension and prediabetic state, assess for hypertension-mediated organ damage 1:

• 12-lead ECG to detect left ventricular hypertrophy or ischemic changes 1
• Echocardiography if ECG is abnormal or if there's clinical suspicion of cardiac dysfunction 1
• Carotid ultrasound to assess for atherosclerotic disease given your cardiovascular risk factors 1

Important Clinical Pitfalls to Avoid

1. Do not dismiss your symptoms as "just stress" or anxiety without completing a thorough organic workup—your symptom complex suggests a specific underlying pathology 1

2. Do not continue metoprolol without considering it as a potential cause of your visual and neurological symptoms—medication-induced symptoms are frequently under-recognized 2, 3

3. Do not delay MRI imaging if symptoms persist or worsen—CT is insufficient for detecting many causes of your symptom complex 1

4. Do not overlook pseudotumor cerebri in an overweight female with headache and visual symptoms—this is a classic presentation requiring specific treatment 1

5. Do not assume your blood pressure is adequately controlled based on office readings alone—consider ambulatory monitoring to detect masked hypertension 1

Algorithmic Approach to Your Evaluation

Step 1: Immediate ophthalmologic examination with fundoscopy to rule out papilledema or hypertensive retinopathy 1

Step 2: MRI brain with and without contrast (including FLAIR sequences) to evaluate for structural lesions, PRES, or signs of elevated intracranial pressure 1

Step 3: If MRI shows signs of elevated intracranial pressure without mass lesion, proceed to lumbar puncture with opening pressure measurement 1

Step 4: Complete laboratory workup including electrolytes, renal function, thyroid function, and screening for secondary hypertension 1, 6

Step 5: Consider trial of alternative antihypertensive medication (discontinue metoprolol, switch to atenolol or different drug class) to assess for medication-related symptoms 2

Step 6: If initial workup is unrevealing, proceed to vestibular testing and ENT evaluation for ear symptoms

Step 7: 24-hour ambulatory blood pressure monitoring to confirm adequate blood pressure control 1