What are the symptoms of high blood pressure?

Hypertension does not cause symptoms in most people.^1-4 There is a common misbelief among patients that hypertension always causes symptoms, but most people with hypertension have no symptoms.^3,4 This lack of significant symptoms and the fact that hypertension is the most common cause of cardiovascular disease is why it has become known worldwide as “The Silent Killer”.^3,5,6

It should be noted this PALS article is discussing mild and moderate hypertension, not hypertensive crisis. People experiencing a hypertensive crisis have dangerously high blood pressure (above 180/120 mm Hg) and clinical signs and/or symptoms of serious organ damage.⁷

Possible Symptoms of Mild or Moderate Hypertension

The World Health Organization (WHO) states that most people with hypertension have no symptoms.³  However, they follow this statement with the acknowledgement that sometimes people can have symptoms, such as headache, dizziness, shortness of breath, nose bleeds, chest pain, and heart palpitations. The WHO also states that these symptoms cannot be relied on to identify people with hypertension.

Studies have tried to determine whether symptoms are caused by high blood pressure and whether symptoms can help identify people for diagnosis. Many studies have found no significant correlation between high blood pressure and symptoms such as headache^8-15, dizziness^13-15, palpitations^13,14, insomnia^13,16,17, epistaxis^10,18-20, and tinnitus^10,14. However, some studies did find an association between high blood pressure and headache^21,22, dizziness¹⁰, nocturia¹⁴, and epistaxis¹⁸. Finally, in some studies, high blood pressure is related inversely to symptoms, such as headache^11,12 and chest pain²³, with fewer people reporting symptoms the higher their blood pressure. This is possibly due to hypertension-related hypoalgesia. Regardless, most studies agree that symptoms are not reliable indicators of blood pressure status.

Hypertension Symptom Study Details

In 1972, Weiss et al. reviewed data from the 1960 to 1962 Health Examination Survey of adults. They analyzed a self-administered medical history form and the blood pressure of 6672 adults.¹⁰ They found no correlation between headache, epistaxis, and tinnitus with high blood pressure. Dizziness was found more often only in people with a very high diastolic pressure (>110 mm Hg), and fainting occurred less often in people with higher blood pressure.

A study done by Chatellier et al. of 1771 adults with untreated hypertension examined symptom prevalence in relation to blood pressure levels.¹⁴ Mean supine systolic blood pressure ± s.d. was 159 ± 28 mm Hg and diastolic was 94 ± 16 mm Hg. Patients had a mean duration of disease ± s.d. of 7.0 ± 8.1 years. The most reported symptoms were headache (40.5% of patients), anxiety (30.7%), emotivity (29.6%), palpitation (28.5%), dizziness (20.8%), nocturia (20.4%), blurred vision (19.1%), insomnia (17.7%), dyspnea (16.8%), chest pain (15.5%), tinnitus (13.7%), and depression (5.6%) (for all, p<0.001). After adjusting for age, the authors found no correlation between blood pressure levels and headaches, palpitation, dizziness, or tinnitus. In men, after age adjustment, only nocturia increased significantly (p<0.01) with systolic blood pressure. In women, no significant correlations were found for the prevalence of symptoms and blood pressure.

A prospective study of 22 685 adults with high blood pressure found that patients with a systolic blood pressure of ≥150 mm Hg had a 30% lower risk (women risk ratio [RR] 0.7, 95% confidence interval [CI] [0.6 – 0.8] and for men RR 0.8, 95% CI [0.7 – 0.9]) of having non-migraine headache compared with those with a systolic blood pressure <140 mm Hg.¹¹ In the multivariable adjusted analysis of the cross-sectional study of 51 336 patients, similar trends were found, but to a lesser degree for the relationship between higher systolic blood pressure and lower risk of headache. However, this analysis found an increased risk of all types of headache for men with a diastolic blood pressure ≥90 mm Hg (odds ratio [OR] 1.2, 95% CI [1.1 – 1.2]) and for migraine-type headache for women with a diastolic blood pressure ≥90 mm Hg (OR 1.2, 95% CI [1.0 – 1.3]).

The HUNT 2 study from 1995-1997 had 13 852 headache-free adult participants.¹² At the time of follow-up for the HUNT 3 study from 2006-2008, 2219 people from the headache-free group had developed any type of headache. Upon analysis, it was found that increasing systolic blood pressure correlated with a decreased incidence of any type of new headache (OR 0.90 per 10 mm Hg increase, 95% CI [0.87 – 0.93], p<0.001). Diastolic blood pressure increases were related to decreasing occurrence of overall headache (OR 0.92 per 10 mm HG increase, 95% CI [0.87 – 1.00], p=0.036).

Middeke et al performed a cross-sectional study of 59 448 participants of which 55 165 were diagnosed hypertensives, 4283 had other diagnoses, and 1399 were the normotensive controls.¹⁵ Their results demonstrated that symptoms can occur in hypertensive patients, and the severity of hypertension correlates with increased symptom reports. In this study, up to 52.9% of untreated hypertensive participants with severe hypertension (≥180/110 mm Hg) and up to 56.7% of treated hypertensives reported morning symptoms attributed to hypertension by the authors. Specific symptoms of dizziness (19.6% vs 13.6%) and headaches (17.0% vs 7.4%) were significantly more likely (p<0.0001) in the 2154 untreated antihypertensive participants as compared with the normotensive participants, respectively.

A 2017 systematic review and meta-analysis of the association between hypertension and epistaxis was performed on 10 studies with 9574 participants total.¹⁸ Min et al found a significantly increased risk of epistaxis for hypertensive patients (odds ratio [OR] 1.532, 95% CI [1.181 – 1.986]. However, the analysis could not prove a causal relationship between hypertension and epistaxis due to limitations in the available studies and because hypertension did not have a significantly increased risk in cohort studies but did in the case-control studies.

Stewart et al enrolled 9427 adults and collected information about their pain symptoms in four areas: chest, leg, back, and gallbladder.²³ The participants were grouped into four blood pressure categories: unaware hypertensives (n=535), previously diagnosed with hypertension but normal blood pressure during study, called aware normotensives (n=7437), diagnosed aware hypertensives (n=520), and normotensives (n=935). The mean age and BMI were higher in hypertensives than normotensives. 25.2% of aware normotensives and 41.9% of aware hypertensives reported current use of antihypertensive medication. This study found that as systolic blood pressure increased, the probability of reporting chest pain (β=-0.009, SE=0.002, Wald=15.78, p<0.05) and gallbladder pain (β=-0.010, SE=0.002, Wald=17.07, p<0.05) decreased in unaware hypertensives. Similarly, for previously diagnosed patients, they found the probability of reporting chest pain (β=-0.006, SE=0.003, Wald=4.18, p<0.05) and gallbladder pain (β=-0.009, SE=0.004, Wald=6.92, p<0.05) decreased as systolic blood pressure increased. In both groups, there was no significant association found between systolic blood pressure and leg or back pain.

Antihypertensive Medication as Source of Symptoms

Some studies examined the prevalence of symptoms between treated and untreated hypertensives and found that certain symptoms like dizziness were more likely to occur in treated patients, suggesting that the symptom was related to the antihypertensive medication rather than the blood pressure itself.^24,25 Vandenburg et al. found that people on antihypertensives are more likely to be on additional medications for other conditions.²⁵ They concluded that other conditions and medications need to be considered when a hypertensive patient reports symptoms.

Hypertension Diagnosis Increases Patient Perception of Symptoms and Illness

Studies have shown that patients who have been told they have hypertension (labeled as hypertensive) are more likely to report symptoms when questioned and perceive a poorer quality of health than undiagnosed hypertensives.^13,23,26,27 This misconception that hypertension is an illness with symptoms adds to people’s anxiety and health concerns. One qualitative study of African American patients demonstrated that people who don’t experience symptoms may not take their medication because they think the condition doesn’t need treatment.²⁸ The authors of the 2003 JNC-7 hypertension guidelines recognized this when they stated that as part of patient education, doctors should emphasize that people cannot tell if their blood pressure is elevated by feelings or symptoms; blood pressure measurement is required for determination.²⁹

In the previously described study by Stewart et al, they demonstrated that unaware hypertensives were significantly less likely than normotensives to report chest pain, and aware hypertensives and aware (previously diagnosed with hypertension) normotensives were significantly more likely to report all types of pain than normotensives.²³ This finding supports earlier studies that suggest that diagnosed patients are more likely to report more symptoms and health concerns.

Another study (n=33 105) demonstrated that aware hypertensive participants (multivariable adjusted OR 1.57, 95% CI [1.41 – 1.74]) had an elevated risk of distress (General Health Questionnaire score ≥4) compared to normotensive participants.²⁶ Unaware hypertensives (OR 0.91, 95% CI [0.78 – 1.07]) did not have an elevated risk of distress. These findings suggest that knowledge of the diagnosis rather than hypertension itself may result in some of the elevated psychological distress.

Symptoms Due to Secondary Hypertension

Up to 10% of hypertension is caused by an underlying condition.^30-33 This is called secondary hypertension. These conditions often cause symptoms. Causes of secondary high blood pressure include:⁷

^References

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