What is the most likely diagnosis and recommended workup for a patient with intermittent 10‑20 second dull headaches and fullness sensation in various locations, occasional non‑vertiginous dizziness, slowed reaction time, memory decline, hypertension spikes at home that improve with Norvasc (amlodipine), and intermittent sharp chest pain over several months, without fever, trauma, positional worsening, Valsalva exacerbation, analgesic overuse, syncope, focal neurologic deficits, or prior similar headaches?

Hypertensive Emergency with Cognitive Symptoms Requiring Urgent Evaluation

This patient requires urgent neuroimaging and blood pressure management for suspected hypertensive emergency with acute end-organ damage manifesting as cognitive dysfunction and intermittent neurological symptoms.

Critical Red Flags Present

This presentation contains multiple concerning features that mandate immediate evaluation:

• Hypertensive spikes at home combined with cognitive symptoms (memory decline, slowed reaction time) suggest hypertensive encephalopathy or acute cerebrovascular pathology 1
• New-onset headache with impaired memory represents a red flag requiring urgent investigation 1, 2
• Non-vertiginous dizziness with cognitive changes in the setting of uncontrolled hypertension raises concern for cerebrovascular insufficiency 1
• The intermittent 10-20 second episodes of headache with fullness sensation, while brief, occur in the context of BP dysregulation and warrant structural evaluation 2, 3

Immediate Diagnostic Workup

Neuroimaging (First Priority)

• MRI brain without contrast is the preferred initial study to evaluate for acute ischemic changes, posterior circulation infarcts, hypertensive encephalopathy, and white matter disease 1, 2, 4
• If MRI is unavailable, CT head without contrast is acceptable as initial imaging, though less sensitive for subtle posterior circulation pathology 2, 4
• The combination of cognitive symptoms, dizziness, and hypertensive spikes makes posterior circulation evaluation critical 1

Blood Pressure Assessment

• Obtain immediate blood pressure measurement to determine if this meets criteria for hypertensive emergency (≥180/110 mmHg with acute organ damage) 1
• The presence of cognitive symptoms (memory decline, slowed reaction time) with BP spikes constitutes acute end-organ damage even without focal neurological deficits 1
• Hypertensive encephalopathy can present with somnolence, lethargy, and cognitive changes before loss of consciousness develops 1

Additional Laboratory Studies

• Complete metabolic panel to assess renal function and electrolytes 4
• Troponin given the intermittent chest pain over several months 1
• ECG to evaluate for cardiac ischemia or arrhythmia contributing to symptoms 1

Most Likely Diagnosis

Hypertensive emergency with hypertensive encephalopathy is the primary concern based on:

• BP spikes requiring medication (amlodipine) for relief 1
• Cognitive dysfunction (memory decline, slowed reaction time) representing acute microangiopathy affecting the brain 1
• Dizziness without vertigo suggesting cerebrovascular insufficiency 1
• The brief 10-20 second headache episodes may represent transient ischemic phenomena in the setting of BP fluctuations 1

Alternative considerations that must be excluded:

• Posterior circulation stroke or TIA given dizziness and cognitive symptoms 1, 2
• Chronic cerebrovascular disease with acute decompensation 1
• Cardiac ischemia given the intermittent chest pain, which could contribute to cerebral hypoperfusion 1

Immediate Management

Blood Pressure Control

• If BP ≥180/110 mmHg with confirmed cognitive symptoms, initiate careful BP reduction with IV therapy targeting 10-20% reduction in the first hour 1
• Continue amlodipine as it provides 24-hour BP control and is effective for hypertensive patients 5, 6, 7
• Avoid rapid BP reduction which can worsen cerebral perfusion 1

Monitoring

• Admit for continuous monitoring if hypertensive emergency is confirmed 1
• Serial neurological examinations to detect progression 1
• Continuous BP monitoring during acute phase 1

Critical Pitfalls to Avoid

• Do not attribute cognitive symptoms to "normal aging" or stress when they occur with documented hypertensive spikes—this represents acute organ damage 1, 2
• Do not delay imaging based on the brief duration (10-20 seconds) of headache episodes; the overall clinical picture with cognitive changes is what matters 2, 3
• Do not treat empirically as primary headache disorder without first excluding secondary causes, especially with new cognitive symptoms 1, 2, 3
• Do not overlook the chest pain—cardiac evaluation is necessary as myocardial ischemia can coexist with hypertensive emergency 1
• Avoid medication overuse headache by not prescribing frequent analgesics until diagnosis is established 1, 2

Follow-up Considerations

• Neurology consultation for ongoing management once acute pathology is excluded or treated 2
• Cardiology evaluation for the intermittent chest pain 1
• Optimize long-term BP control with medication adjustment as needed; amlodipine has proven efficacy but may require combination therapy 5, 6, 8
• Headache diary to track symptoms if primary headache disorder is ultimately diagnosed 1, 2