How can we manage hypertension in a newly diagnosed adult patient with no significant past medical history who is presenting with headache?

Management of Hypertension in a Newly Diagnosed Adult with Headache

Begin with lifestyle modifications immediately and initiate pharmacological therapy based on blood pressure level and cardiovascular risk assessment. 1, 2

Initial Evaluation and Risk Assessment

First, confirm the diagnosis with proper blood pressure measurement technique:

• Measure BP with patient seated, back supported, arm at heart level, after 3-5 minutes of rest 2
• Take at least two measurements per visit and average them 2
• Consider ambulatory BP monitoring (≥130/80 mmHg over 24 hours) or home BP monitoring (≥135/85 mmHg) to confirm diagnosis and exclude white coat hypertension 2

Obtain baseline laboratory investigations: 1, 2

• Fasting blood glucose
• Complete blood count
• Lipid profile (total cholesterol and HDL)
• Serum creatinine with eGFR
• Serum electrolytes (sodium, potassium, calcium)
• Thyroid-stimulating hormone
• Urinalysis
• 12-lead electrocardiogram

Calculate 10-year ASCVD risk to guide treatment intensity 1

Addressing the Headache

The headache is likely related to the hypertension itself, as mild-to-moderate hypertension is associated with increased headache incidence, particularly in younger patients (<50 years) and women. 3 Antihypertensive treatment has been shown to significantly reduce headache incidence (p=0.003) 3

Rule out hypertensive emergency: 1

• If BP >180/120 mmHg with severe headache, visual disturbances, or neurologic symptoms, evaluate immediately for hypertensive encephalopathy
• Perform fundoscopy to assess for papilledema, hemorrhages, or cotton wool spots 1
• If no acute end-organ damage is present, this is not a hypertensive emergency and can be managed with oral therapy 1

Lifestyle Modifications (Initiate Immediately for All Patients)

Weight reduction if BMI >25 kg/m²: 2, 4

• Target approximately 1 mmHg reduction per kg lost
• This is the most effective single lifestyle intervention

Dietary modifications: 2, 4

• Adopt DASH (Dietary Approaches to Stop Hypertension) eating plan
• Restrict sodium to <2,000 mg/day (can reduce BP by 5-6 mmHg) 2
• Increase potassium intake through diet

Physical activity: 1, 4

• Aerobic exercise reduces SBP by 5-8 mmHg in hypertensive patients
• Recommend regular physical activity

Alcohol moderation: 1, 4

• Limit to ≤2 standard drinks per day for men, ≤1 for women
• Those consuming ≥6 drinks/day who reduce by 50% experience average SBP/DBP reduction of 5.5/4.0 mmHg 1

Pharmacological Therapy Decision Algorithm

For Stage 1 Hypertension (130-139/80-89 mmHg): 1

• If 10-year ASCVD risk <10%: Lifestyle modifications alone, reassess in 3-6 months 1
• If 10-year ASCVD risk ≥10%: Initiate both lifestyle modifications AND pharmacological therapy, reassess in 1 month 1

For Stage 2 Hypertension (≥140/90 mmHg): 1, 2

• Initiate combination therapy with TWO agents from different classes immediately 1
• Reassess in 1 month 1

For very high BP (SBP ≥180 or DBP ≥110 mmHg): 1

• Prompt evaluation and immediate antihypertensive drug treatment 1

First-Line Pharmacological Therapy

The preferred initial regimen is a single-pill combination of: 2, 4

• A renin-angiotensin system blocker (ACE inhibitor or ARB) PLUS
• A calcium channel blocker OR thiazide-type diuretic 2

Specific drug recommendations: 2, 4

• Thiazide-like diuretics (chlorthalidone or indapamide) are superior to hydrochlorothiazide for 24-hour BP control 2
• ACE inhibitor: Lisinopril 10-40 mg daily 5
• ARB: Losartan 50-100 mg daily 6
• Thiazide-like diuretic: Chlorthalidone 25-50 mg daily 7

For Stage 2 hypertension, start with two-drug combination: 1, 2

• Example: ACE inhibitor/ARB + calcium channel blocker
• Or: ACE inhibitor/ARB + thiazide diuretic

Blood Pressure Targets

Target BP <130/80 mmHg for most adults <65 years 2, 4

Target SBP <130 mmHg for adults ≥65 years 2, 4

Follow-Up Schedule

• Stage 1 hypertension with low ASCVD risk: Reassess in 3-6 months 1
• Stage 1 hypertension with high ASCVD risk or Stage 2 hypertension: Reassess in 1 month 1
• Normal BP: Annual reassessment 1

Common Pitfalls to Avoid

Do not use beta-blockers as first-line therapy unless there are specific compelling indications (e.g., coronary artery disease, heart failure) 1

Avoid simultaneous use of ACE inhibitor + ARB + renin inhibitor - this combination is potentially harmful 1

Do not overlook secondary causes in young patients (<30 years): 1, 2

• Screen for renal parenchymal disease, renovascular hypertension, primary aldosteronism, obstructive sleep apnea, and drug-induced hypertension 2
• Young adults have higher likelihood of identifiable and treatable causes 2

Screen for primary aldosteronism if: 8

• Resistant hypertension (uncontrolled on ≥3 medications including a diuretic)
• Spontaneous or diuretic-induced hypokalemia
• Family history of early-onset hypertension or stroke at young age (<40 years)
• Use plasma aldosterone concentration to plasma renin activity ratio as screening test 8