High blood pressure (hypertension)

• Usually nothing at all — most people with high blood pressure feel entirely well
• Headache, particularly at the back of the head in the morning, when pressure is very high
• Breathlessness on exertion, if the heart muscle has begun to thicken
• Nosebleeds, palpitations or visual disturbance at severe levels
• Because symptoms are unreliable, blood pressure is a measurement rather than a feeling

• Family history — hypertension runs strongly in families
• High dietary salt, which matters more in some people than others
• Excess weight, particularly around the abdomen
• Physical inactivity
• Alcohol
• Chronic stress and poor or fragmented sleep, including obstructive sleep apnoea
• Kidney disease, thyroid disorders and certain hormonal conditions, which cause a minority of cases but are worth excluding in the young or in resistant cases
• Some medications, including certain painkillers, steroids and decongestants

• Repeated, properly taken readings — seated, arm supported at heart level, correct cuff size, after five minutes of rest
• Readings in both arms at the first visit
• Home blood pressure readings over a week, which often reflect true pressure better than clinic readings
• 24-hour ambulatory monitoring, where clinic and home readings disagree or where readings rise only in the clinic
• Blood tests for kidney function, electrolytes, blood sugar and lipids
• An ECG, and echocardiography where thickening of the heart muscle is suspected

A diagnosis of hypertension commits someone to long-term treatment, so it is worth establishing properly rather than on one reading.

• Salt reduction, weight loss where relevant, regular activity and moderation of alcohol — these are genuinely effective, not a preamble to the real treatment
• Medication, usually one drug to begin with, adjusted over follow-up visits
• Combination therapy where a single drug does not achieve target, which is common and not a sign of failure
• Treating the associated risks — cholesterol and blood sugar — because they compound
• Home monitoring, so decisions are made on real numbers rather than occasional clinic readings
• Investigation for a secondary cause where hypertension is severe, resistant to three drugs, or appears in someone young

Blood pressure medication is generally long term. Stopping it because the readings have normalised is the commonest reason control is lost — the readings are normal because of the treatment.

• Have your blood pressure measured at least once a year from your thirties, and earlier if it runs in the family.
• Reduce added salt, and be aware that most dietary salt comes from processed and restaurant food rather than the salt shaker.
• Keep up regular activity — it lowers blood pressure independently of weight loss.
• Treat snoring with daytime sleepiness seriously; sleep apnoea is a common and treatable driver of resistant hypertension.