What is the appropriate management for a patient with a new severe throbbing headache and elevated blood pressure, differentiating hypertensive emergency (systolic ≥180 mm Hg or diastolic ≥120 mm Hg) from hypertensive urgency?

Management of High Blood Pressure with Headache

Immediate Classification: Emergency vs. Urgency

The presence or absence of acute target-organ damage—not the blood pressure number—determines whether you have a hypertensive emergency requiring ICU admission or a hypertensive urgency managed with oral medications. 1

Rapid Bedside Assessment for Target-Organ Damage

Perform a focused evaluation within minutes to identify acute organ injury:

• Neurologic signs – Altered mental status, seizures, severe headache with vomiting, visual loss, focal deficits, or somnolence indicate possible hypertensive encephalopathy or stroke and mandate emergency classification 1
• Cardiac symptoms – Chest pain or dyspnea with pulmonary edema suggest acute coronary syndrome or left-ventricular failure 1
• Fundoscopy – Bilateral retinal hemorrhages, cotton-wool spots, or papilledema (grade III-IV retinopathy) define malignant hypertension; isolated subconjunctival hemorrhage is NOT target-organ damage 1
• Laboratory screening – Complete blood count, creatinine, electrolytes, LDH, haptoglobin, urinalysis, troponin, and ECG to detect thrombotic microangiopathy, acute kidney injury, or cardiac injury 1

Critical distinction: A patient with BP 180/120 mmHg and isolated headache (without vomiting, altered consciousness, or fundoscopic changes) has hypertensive urgency, not emergency. 1

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Management of Hypertensive Emergency (Target-Organ Damage Present)

ICU Admission and Monitoring

• Immediate ICU admission with continuous arterial-line monitoring is a Class I recommendation 1
• Parenteral IV therapy is mandatory; oral agents are inadequate 1

Blood Pressure Reduction Strategy

For most emergencies (without compelling conditions):

• First hour: Reduce mean arterial pressure by 20-25% (or systolic ≤25%) 1
• Hours 2-6: Lower to ≤160/100 mmHg if stable 1
• Hours 24-48: Gradually normalize blood pressure 1
• Avoid systolic drops >70 mmHg to prevent cerebral, renal, or coronary ischemia, especially in chronic hypertensives with altered autoregulation 1

For compelling conditions, more aggressive targets apply:

Condition	Target SBP	Timeframe
Aortic dissection	<120 mmHg	Within 20 minutes
Severe preeclampsia/eclampsia	<140 mmHg	Within first hour
Acute coronary syndrome/pulmonary edema	<140 mmHg	Immediately
Acute intracerebral hemorrhage (SBP ≥220)	140-180 mmHg	Within 6 hours

1

First-Line IV Medications

Nicardipine (preferred for most emergencies except acute heart failure):

• Start 5 mg/h IV infusion, increase by 2.5 mg/h every 15 minutes to maximum 15 mg/h 1
• Preserves cerebral blood flow without raising intracranial pressure 1
• Predictable, titratable control with rapid onset (5-15 min) and short duration (30-40 min) 1
• Avoid in acute heart failure due to reflex tachycardia 1

Labetalol (preferred for aortic dissection, eclampsia, malignant hypertension with renal involvement):

• 10-20 mg IV bolus over 1-2 minutes, repeat or double every 10 minutes (max cumulative 300 mg) 1, 2
• Alternative: continuous infusion 2-8 mg/min 1, 2
• Contraindicated in reactive airway disease, COPD, heart block, bradycardia, decompensated heart failure 1, 2

Clevidipine (alternative rapid-acting CCB):

• Start 1-2 mg/h IV infusion, double every 90 seconds until near target, then <2-fold every 5-10 minutes; max 32 mg/h 1
• Contraindicated in soy/egg allergy 1

Sodium nitroprusside (last-resort only):

• 0.25-10 µg/kg/min IV infusion 1
• Requires thiosulfate co-administration when ≥4 µg/kg/min or >30 minutes to prevent cyanide toxicity 1

Condition-Specific Regimens

• Acute coronary syndrome/pulmonary edema – IV nitroglycerin 5-100 µg/min ± labetalol; avoid nicardipine monotherapy (reflex tachycardia worsens ischemia) 1
• Aortic dissection – Esmolol loading 500-1000 µg/kg, then infusion 50-200 µg/kg/min before any vasodilator; add nitroprusside or nitroglycerin to achieve SBP ≤120 mmHg and HR <60 bpm within 20 minutes 1
• Eclampsia/severe preeclampsia – Labetalol, hydralazine, or nicardipine; ACE inhibitors, ARBs, and nitroprusside are absolutely contraindicated 1
• Hypertensive encephalopathy – Nicardipine is superior (preserves cerebral perfusion without raising intracranial pressure); labetalol is acceptable alternative 1

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Management of Hypertensive Urgency (No Target-Organ Damage)

Patients can be managed with oral agents and outpatient follow-up; hospitalization is NOT required. 1

Blood Pressure Reduction Strategy

• Gradual reduction over 24-48 hours to <160/100 mmHg 1
• Then aim for <130/80 mmHg over subsequent weeks 1
• Rapid lowering is discouraged because it may precipitate cerebral, renal, or coronary ischemia in chronic hypertensives 1

Preferred Oral Agents

• Extended-release nifedipine 30-60 mg PO 1
• Captopril 12.5-25 mg PO (risk of abrupt BP fall in volume-depleted patients) 1
• Labetalol 200-400 mg PO (contraindicated in reactive airway disease, heart block, bradycardia) 1

Never use immediate-release nifedipine – unpredictable precipitous drops, stroke, and death 1

Follow-Up

• Arrange outpatient review within 2-4 weeks 1
• Aim for BP <130/80 mmHg (or <140/90 mmHg in elderly/frail) within 3 months 1
• Observe patient for at least 2 hours after medication administration 1

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Post-Stabilization and Long-Term Management

Screen for Secondary Causes

20-40% of malignant hypertension cases have identifiable etiologies: 1

• Renal artery stenosis
• Pheochromocytoma
• Primary aldosteronism
• Renal parenchymal disease

Address Medication Non-Adherence

Medication non-adherence is the most common trigger for hypertensive emergencies. 1

Long-Term Follow-Up

• Monthly visits until target BP achieved and organ-damage regresses 1
• Transition to oral regimen combining renin-angiotensin system blocker, calcium-channel blocker, and diuretic 1
• Patients with prior emergency remain at markedly increased cardiovascular and renal risk 1

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Critical Pitfalls to Avoid

• Do not admit asymptomatic severe hypertension without target-organ damage (urgency, not emergency) 1
• Do not use oral agents for hypertensive emergencies; IV therapy is mandatory 1
• Do not use immediate-release nifedipine – risk of precipitous BP fall, stroke, and death 1
• Do not rapidly lower BP in hypertensive urgency; gradual reduction is essential 1
• Do not normalize BP acutely in chronic hypertensives; altered autoregulation predisposes to ischemic injury 1
• Do not use hydralazine as first-line therapy (unpredictable response and prolonged duration) 1
• Reserve sodium nitroprusside for last-resort use due to cyanide toxicity risk 1
• Do not dismiss the "normal" BP reading on presentation; patients with hypertensive emergencies may have fluctuating BP 1
• Up to one-third of patients with diastolic >95 mmHg normalize before follow-up; overly aggressive reduction can be harmful 1

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Prognosis

Untreated hypertensive emergencies carry >79% one-year mortality and median survival of only 10.4 months. 1