What is the best medication for a patient with hypertension, anxiety, insomnia, and motor‑behaviour (rocking)?

Management of Hypertension, Anxiety, Insomnia, and Motor Restlessness (Rocking)

For a patient presenting with hypertension, anxiety, insomnia, and motor restlessness (rocking behavior), the optimal medication is mirtazapine 7.5–15 mg at bedtime, which addresses all four conditions simultaneously while avoiding agents that could worsen blood pressure or cause additional movement disorders.

Clinical Assessment Priorities

Before initiating treatment, rapidly assess for:

• Hypertensive emergency vs. urgency: Check for acute target-organ damage including altered mental status, severe headache with vomiting, visual changes, chest pain, or dyspnea—if present, this requires immediate ICU admission and IV therapy 1
• Akathisia vs. anxiety: The "rocking while talking" suggests possible akathisia (antipsychotic-induced motor restlessness) rather than simple anxiety—inquire about recent antipsychotic use or dose changes 2, 3
• Blood pressure severity: Confirm BP >180/120 mmHg with proper technique; the presence or absence of target-organ damage—not the absolute number—determines urgency of intervention 1

Medication Selection Algorithm

First-Line: Mirtazapine (Addresses All Four Conditions)

Mirtazapine 7.5–15 mg at bedtime is the single best agent because it:

• Treats insomnia effectively through sedating antihistamine (H1) effects 4
• Reduces anxiety via serotonergic mechanisms 4
• Manages akathisia with strong evidence as a rescue agent (part of the "B-CALM" mnemonic) 2
• Does not worsen hypertension and may have neutral or slightly beneficial cardiovascular effects 4
• Avoids benzodiazepine risks in elderly patients (falls, cognitive impairment, dependence) 4

Dosing: Start 7.5 mg at bedtime; if insufficient response after 1 week, increase to 15 mg at bedtime 4. Note that lower doses (7.5 mg) are often more sedating than higher doses due to antihistamine predominance 4.

Second-Line: Add Propranolol for Persistent Akathisia

If rocking/motor restlessness persists despite mirtazapine:

• Propranolol 10–20 mg three times daily has the strongest evidence for akathisia management 2
• Dual benefit: Also lowers blood pressure, addressing hypertension 4
• Contraindications: Avoid in reactive airway disease, COPD, heart block, bradycardia, or decompensated heart failure 1
• Alternative if propranolol contraindicated: Clonazepam 0.5 mg twice daily (part of "B-CALM"), though this carries benzodiazepine risks 2

Hypertension Management

If Hypertensive Urgency (BP >180/120 without organ damage):

• Do NOT use IV medications—oral therapy with outpatient follow-up is appropriate 1
• Add extended-release nifedipine 30–60 mg once daily if BP remains >160/100 mmHg after 24–48 hours on mirtazapine 1
• Never use immediate-release nifedipine—it causes unpredictable precipitous drops, stroke, and death 1
• Target: Gradual reduction to <160/100 mmHg over 24–48 hours, then <130/80 mmHg over subsequent weeks 1

If Hypertensive Emergency (BP >180/120 WITH organ damage):

• Immediate ICU admission with continuous arterial-line monitoring (Class I recommendation) 1
• IV nicardipine 5 mg/hr, titrate by 2.5 mg/hr every 15 minutes (max 15 mg/hr) 1
• Target: Reduce mean arterial pressure by 20–25% in first hour, then to ≤160/100 mmHg over 2–6 hours 1

Medications to AVOID

• Benzodiazepines as first-line: While effective for anxiety and insomnia, they carry high risks in this population—cognitive impairment, falls, fractures, addiction, and rebound hypertension on withdrawal 4
• Typical antipsychotics: Will worsen akathisia/motor restlessness 2
• Phentermine or other sympathomimetics: Contraindicated due to hypertension and anxiety—these agents increase BP and heart rate 4
• Clonidine for insomnia: Reserved as last-line due to significant CNS adverse effects and rebound hypertensive crisis risk upon discontinuation 4, 1
• Diphenhydramine/hydroxyzine: Less effective than mirtazapine for insomnia and may worsen akathisia 4

Monitoring and Follow-Up

• Week 1: Assess response to mirtazapine—improvement in sleep, anxiety, and motor restlessness 2
• Week 2–4: Recheck BP; if still >160/100 mmHg, add extended-release nifedipine or propranolol 1
• Monthly: Continue follow-up until BP <130/80 mmHg and all symptoms controlled 1
• Screen for secondary hypertension: 20–40% of malignant hypertension cases have identifiable causes (renal artery stenosis, pheochromocytoma, primary aldosteronism) 1
• Address medication adherence: Non-adherence is the most common trigger for hypertensive emergencies 1

Critical Pitfalls to Avoid

• Do not rapidly lower BP in hypertensive urgency—this causes cerebral, renal, or coronary ischemia, especially in chronic hypertensives with altered autoregulation 1
• Do not dismiss motor restlessness as "just anxiety"—subtle akathisia can manifest as rocking and fidgeting without obvious pacing, and untreated akathisia contributes to behavioral dyscontrol 3
• Do not use multiple sedating agents simultaneously—combining benzodiazepines with mirtazapine increases fall risk and respiratory depression 4
• Do not ignore the bidirectional relationship between insomnia and hypertension—treating insomnia may improve BP control, and vice versa 5, 6, 7
• Do not assume absence of symptoms equals absence of hypertensive target-organ damage—perform focused neurologic exam, fundoscopy, and cardiac assessment 1

Evidence Strength Note

The recommendation for mirtazapine is based on convergent evidence from multiple guidelines: it appears in insomnia guidelines as a sedating antidepressant option 4, in akathisia management as part of the "B-CALM" evidence-based algorithm 2, and in obesity/medication guidelines as weight-neutral to weight-gain promoting (acceptable in anxious patients who may have poor appetite) 4. The hypertension management follows the most recent ACC/AHA and ESC guidelines 1, 4.