Original article 437
Headache in patients with mild to moderate hypertension is
generally not associated with simultaneous blood pressure
elevation
Piotr Kruszewski, Leszek Bieniaszewski, Jolanta Neubauer and
Barbara Krupa-Wojciechowska
Objective Although headache is regarded a symptom of
hypertension, its relation to blood pressure, especially in
mild and moderate hypertension, is not clear. Thus, the aim
of the study was to investigate whether headache in
patients with mild to moderate hypertension may be
attributed to simultaneous elevations in blood pressure.
Design and methods Ambulatory blood pressure
monitoring (ABPM) was performed in patients (mean age
48 6 10 years, n = 150, 92 men, 58 women) classi®ed,
according to their of®ce blood pressure, as stage 1±2
hypertensives (JNC VI). Headache periods were recorded
in patients' diaries.
Results Headaches were generally not directly associated
with blood pressure elevations in the studied group of
stage 1±2 hypertensive patients because (i) blood
pressure values from headache periods were not
signi®cantly higher than those from headache-free
periods; (ii) blood pressure values directly preceding the
pain were not signi®cantly different from values at the
beginning of headache; and (iii) in the vast majority of
hypertensives, their maximal blood pressure values were
recorded during headache-free periods. Moreover, in some
Introduction
Headache is generally regarded a symptom of high
blood pressure, in spite of con¯icting opinions in the
literature about association of headache and arterial
hypertension [1±11]. This association is especially un-
clear in mild and moderate hypertension (stage 1±2
according to JNC VI [12]). Blood pressure measure-
ments were not systematically performed during head-
ache episodes in the previous studies. The in¯uence of
blood pressure, or lack of such in¯uence, on headache
was estimated by comparing the frequency of head-
aches reported by patients in different groups (e.g.
hypertensives versus normotensives, or hypertensives
before versus after treatment).
Therefore, the aim of the present study was to
investigate, utilizing a 24 h ambulatory blood pres-
sure monitoring (ABPM) technique, whether head-
ache in patients with stage 1±2 hypertension may be
0263-6352 & 2000 Lippincott Williams & Wilkins
instances, patients who showed maximal ABPM values
during headache had relatively high blood pressure, i.e.
> 180/110 mmHg.
Conclusions Our results did not support the opinion that
headache experienced by stage 1±2 hypertensives was
generally caused by simultaneous elevation in blood
pressure. The direct mechanisms of headache in
hypertension, as well as the relation between increments
in blood pressure above 180/110 mmHg and headache,
need further investigations. J Hypertens 2000, 18:437±444
& Lippincott Williams & Wilkins.
Journal of Hypertension 2000, 18:437±444
Keywords: ambulatory blood pressure monitoring, arterial hypertension,
headache
Department of Hypertension and Diabetology. Medical University of Gdansk,
Poland.
Correspondence and requests for reprints to Piotr Kruszewski MD PhD,
Department of Hypertension and Diabetology, Medical University of Gdansk,
Debinki 7, 80-211 Gdansk, Poland.
Fax: ‡48 58 349 23 41; e-mail: pkruszew@amedec.amg.gda.pl
Received 8 July 1999 Revised 8 December 1999
Accepted 4 January 2000
attributed to simultaneous elevations in blood pres-
sure.
Design and methods
ABPM was performed in individuals referred to our
clinic (mean age 48  10 years, n ˆ 150, 92 men, 58
women, see Table 1), classi®ed as stage 1±2 hyper-
tensive patients on the basis of of®ce blood pressure
measurements (JNC VI [12]: systolic blood pressure
(SBP) 140±179 mmHg and/or diastolic blood pressure
(DBP) 90±109 mmHg). SpaceLabs 90207 devices were
used for ABPM. Blood pressure was measured every
20 min from 0600±2200 h and every 30 min from 2200±
0600 h.
Patients were asked to indicate in the diaries their
activity (assuming supine position, sleep time), time of
receiving medication as well as time periods when they
experienced headache during ABPM. Patients were
438 Journal of Hypertension 2000, Vol 18 No 4

Table 1 Group characteristics.

Patients without Patients with
headache during headache during
All patients ABPM ABPM

Number 150 105 45

Age (years) 48 (42±55) 49 (42±55) 48 (44±53)
Body mass index (kg/m2 ) 28.1 (25.1±30.6) 28.2 (25.4±30.8) 27.9 (24.7±30.1)
ABPM variables (mmHg)
SBP24 h 131 (124±139) 132 (124±139) 131 (124±142)
DBP24 h 84 (78±90) 84 (78±89) 84 (78±90)
SBPD 135 (126±145) 135 (127±145) 133 (126±145)
DBPD 88 (82±94) 88 (80±94) 88 (84±94)
SBPN 116 (107±126) 116 (107±126) 116 (107±127)
DBPN 72 (66±79) 72 (66±79) 72 (62±80)

Values are median (25th ±75th percentile). ABPM, ambulatory blood pressure monitoring; SBP,
systolic blood pressure; DBP, diastolic blood pressure. D, daytime mean: all measurements between
1000 and 2000 h. N, night-time mean: all measurements between 0000 and 0600 h. 24 h, 24 h
mean: average of all measurements performed during ABPM.

asked to try not to use analgesic drugs if they felt they
could manage without them. Thus, only three patients
took non-steroidal anti-in¯ammatory drugs after devel-
oping headache. There were 55 non-medicated patients
in our study (Table 2). The remaining 95 patients were
receiving one drug (n ˆ 61), two drugs (n ˆ 25), or
more than two drugs (n ˆ 9). The group of medicated
subjects was broken down into ®ve subgroups according
to the drug class used (Table 2). In cases where more
than one drug was taken, the patient belonged to more
than one subgroup. Only individual patients received
other drugs than those included in the ®ve subgroups.
Means of SBP and DBP, based on 1 h means, of the
entire 24 h period, daytime (1000±2000 h) and night-
time (0000±0600 h) as well as mean values for head-
ache and headache-free periods were calculated. In
order to avoid an in¯uence of body position on blood
pressure, periods when the patients assumed a supine
position were excluded from further calculations of
headache and headache-free means for SBP and DBP.
The Wilcoxon matched pairs test was used for compari-
sons of blood pressure values, and the ÷2 test with
Yates correction where appropriate was used for com-
parisons of proportions of subjects with headache and
without headache in the studied group and its sub-
groups.
Results
Episodes of headache during ABPM were reported in
45 out of 150 (i.e. 30%) patients' diaries. A similar
percentage of patients experiencing headache during
ABPM as that observed in the entire group, was found
in the subgroup of non-medicated individuals or those
with daytime ambulatory blood pressure levels > 135/
85 mmHg (Table 2). Moreover, the percentage of pa-
tients with headache in any of the ®ve subgroups of
treated patients did not differ signi®cantly from the
percentage for non-medicated subjects (Table 2).
The group of patients who suffered from headache
during ABPM did not differ signi®cantly from the

Table 2 Number of patients in different subgroups studied, divided into those without
headache and those experiencing headache during ambulatory blood pressure
monitoring (ABPM)
Patients without Patients with
headache during headache during
Group of patients All patients ABPM ABPM

Total 150 105 (70%) 45 (30%)

With BPD > 135/85 mmHg 102 72 (71%) 30 (29%)
Non-medicated 55 38 (69%) 17 (31%)
Non-medicated with BPD > 135/85 mmHg 45 31 (69%) 14 (31%)
Medicated 95 67 (71%) 28 (29%)
Treated with diuretics 49 35 (71%) 14 (29%)
Treated with ACE inhibitors 44 31 (70%) 13 (30%)
Treated with â-blockers 16 8 (50%) 8 (50%)
Treated with calcium antagonists 13 10 (77%) 3 (23%)
Treated with nitrates 11 8 (73%) 3 (27%)

BPD , daytime mean of ambulatory blood pressure: all measurements between 1000 and 2000 h.  Some
patients were treated with more than one drug. ACE, angiotensin converting enzyme.
 Blood pressure and headache Kruszewski et al. 439

group of patients who did not experience headache
during the studied period in terms of age, body mass
index, and 24 h, daytime and night-time means of both
SBP and DBP (Table 1). The duration of headaches
ranged from 0.5 to 16 h (median 3 h).
For a few patients, headache appeared when blood
pressure values were relatively high, although in
these same patients, headache was sometimes ob-
served when blood pressure was relatively low, or no
headache was observed with blood pressure values
higher than those from the headache period. On the
other hand, there were several pro®les for which no
clear association between changes in blood pressure
and headache could be found. There were also
individual pro®les with headaches appearing when
blood pressure was relatively low. Examples of
individual blood pressure pro®les of patients report-
ing headache during the ABPM are displayed in
Figure 1.

Fig. 1

[mmHg] [mmHg]
200 a 200 b
180 180
160 160
140 140
120 120
100 100
80 80
60 60
40 40
08.00 16.00 24.00 08.00 08.00 16.00 24.00 08.00
clock time clock time
[mmHg] [mmHg]
200 c 200 d
180 180
160 160
140 140
120 120
100 100
80 80
60 60
40 40
08.00 16.00 24.00 08.00 08.00 16.00 24.00 08.00
clock time clock time

[mmHg] [mmHg]
200 e 200 f

180 180
160 160
140 140
120 120
100 100
80 80
60 60
40 40
08.00 16.00 24.00 08.00 08.00 16.00 24.00 08.00

clock time clock time

SBP DBP Headache

Examples of individual blood pressure pro®les in patients who experienced headache during ABPM. SBP, systolic blood pressure; DBP, diastolic
blood pressure.
440 Journal of Hypertension 2000, Vol 18 No 4

Three patients out of 45 experiencing headache during
ABPM were excluded from further analysis: one patient
reporting continuous pain, because of lack of headache-
free-period for comparison, and two patients experien-
cing headache in the supine position. Thus, 42 ABPM
pro®les were analysed in order to compare blood
pressure during headache versus headache-free periods.
The analysis of these 42 blood pressure pro®les
revealed that SBP and DBP levels from headache
periods were not signi®cantly different from means for
headache-free periods (Table 3).
18 pro®les for DBP, the ®rst 1 h mean during headache
period was higher than the last 1 h mean prior to the
headache, whereas in remaining 19 and 20 pro®les,
respectively, the situation was opposite. When differ-
ences > 5 mmHg were taken into consideration, the
corresponding numbers of patients were 10 (SBP) and
11 (DBP) for increase in blood pressure and 10 (SBP)
and 11 (DBP) for decrease in blood pressure; for
differences > 10 mm Hg, the numbers were 5 (SBP)
and 6 (DBP) for increase in blood pressure and 3 (both
SBP and DBP) for decrease in blood pressure.

In 38 out of those 42 patients, it was possible to
compare SBP and DBP 1 h means directly preceding
headache onset with means from the ®rst hour of the
headache period. No signi®cant differences were found
with this approach (Table 4). When differences of the
®rst 1 h means from headache period and 1 h means
directly prior to headache onset were calculated, the
maximal increase was 22 mmHg for SBP and 18 mmHg
for DBP, and the maximal decrease was 43 mmHg for
SBP and 13 mmHg for DBP. In 19 pro®les for SBP and
When maximal 1 h means from headache periods were
compared with those from headache-free periods, the
former were signi®cantly lower, both for SBP and DBP
(Table 5). For 33 SBP pro®les and 35 DBP pro®les, it
was possible to determine at least one 1 h mean in a
headache-free period (median 4, range 1±15) that was
greater than the maximal 1 h mean from a headache
period (Fig. 2). Only in nine instances for SBP and
seven for DBP were maximal values of 1 h means
observed in headache periods.

Table 3 Comparison of mean blood pressure values from headache-free periods versus headache periods
Non-medicated
Patients with Non-medicated patients with
All patients BPD > 135/85 mmHg patients BPD > 135/85 mmHg

Number 42 27 15 12
Systolic blood pressure (mmHg)
Headache-free period 134 (128±147) 143 (133±153) 139 (131±147) 141 (134±149)
Headache period 135 (127±154) 144 (135±156) 139 (131±154) 143 (134±155)
Diastolic blood pressure (mmHg)
Headache-free period 90 (82±95) 94 (89±99) 89 (84±95) 92 (88±95)
Headache period 91 (83±96) 95 (90±100) 92 (85±96) 93 (87±97)

Data are presented as medians (25th±75th percentile). The Wilcoxon matched pair test was used for comparison between
headache-free and headache periods. None of the differences were statistically signi®cant. BPD , daytime mean of ambulatory
blood pressure: all measurements between 1000 and 2000 h.  From the total of 45 patients, three who experienced headache
during ABPM were excluded (see Results). Therefore, the numbers of patients are smaller than the numbers displayed in Table 2.

Table 4 Comparison of last 1 h mean prior to headache versus the ®rst 1 h mean during the headache
period
Non-medicated
Patients with Non-medicated patients with
All patients BPD > 135/85 mmHg patients BPD > 135/85 mmHg

Number 38 25 14 11
Systolic blood pressure (mmHg)
Last hour before headache 136 (123±155) 145 (130±157) 141 (130±151) 145 (132±156)
First hour of headache 137 (128±152) 144 (135±155) 137 (129±150) 141 (129±154)
Diastolic blood pressure (mmHg)
Last hour before headache 88 (83±97) 92 (85±102) 90 (85±96) 92 (89±99)
First hour of headache 89 (84±96) 93 (87±99) 88 (85±93) 90 (86±93)

Data are presented as medians (25th±75th percentile). The Wilcoxon matched pair test was used for comparison between
headache-free and headache periods. None of the differences were statistically signi®cant. BPD , daytime mean of ambulatory
blood pressure: all measurements between 1000 and 2000 h.  From the total of 45 patients, three who experienced headache
during ABPM were excluded (see Results). In an additional four patients, it was not possible to determine the mean for the 1 h
period prior to headache because the patients had assumed a supine position (see Results). Therefore, the numbers of patients
are smaller than the numbers displayed in Table 2.
 Blood pressure and headache Kruszewski et al. 441

Table 5 Comparison of maximal 1 h means from headache-free period versus headache period
Non-medicated
Patients with Non-medicated patients with
All patients BPD > 135/85 mmHg patients BPD > 135/85 mmHg

Number 42 27 15 12
Systolic blood pressure (mmHg)
Headache-free period 152 (145±171) 159 (150±175) 152 (150±171) 157 (152±173)
Headache period 142 (132±155) 151 (136±170) 143 (134±155) 145 (136±157)
P value , 0.001 0.001 0.005 0.015
Diastolic blood pressure (mmHg)
Headache-free period 102 (96±109) 105 (101±114) 102 (96±109) 103 (101±110)
Headache period 96 (86±101) 97 (92±109) 92 (86±101) 96 (88±102)
P value , 0.001 0.001 0.003 0.012

Data are presented as medians (25th±75th percentile). The Wilcoxon matched pair test was used for comparison between
headache-free and headache periods. BPD , daytime mean of ambulatory blood pressure: all measurements between 1000 and
2000 h.  From the total of 45 patients, three who experienced headache during ABPM were excluded (see Results). Therefore,
the numbers of patients are smaller than the numbers displayed in Table 2.

Fig. 2

16 Systolic blood pressure 16 Diastolic blood pressure

14 14
12 12
Number of patients

Number of patients

10 10
8 8
6 6
4 4
2 2
0 0
0 1–2 5–6 9–10 13–14 0 1–2 5–6 9–10 13–14
3–4 7–8 11–12 15–16 3–4 7–8 11–12 15–16
Number of 1-h means Number of 1-h means

Number of systolic and diastolic blood pressure 1 h means from headache-free periods greater than the maximal 1 h mean from the headache
period in each of 42 blood pressure pro®les of patients who experienced headache during ABPM.

Blood pressure values > 180 mmHg (SBP) and/or
110 mmHg (DBP) were observed in ®ve subjects
during headache periods. However, even in some of
these patients, one could observe higher or comparable
blood pressure values in headache-free periods.
Similar results to those observed in the entire studied
group of patients with headache during ABPM were
obtained when patient series were limited to: (i) only
patients with average daytime blood pressure > 135/
85 mmHg, (ii) only non-medicated patients, and (iii)
only non-medicated patients with average daytime blood
pressure > 135/85 mmHg (Tables 3±5). Overall results
were not altered when the analysis was repeated ®ve
times, each time excluding patients treated with one
class of drugs ± diuretics, angiotensin converting en-
zyme (ACE) inhibitors, â-blockers, calcium antagonists
and nitrates ± from the studied series (data not shown).
Discussion
Headache is a very common complaint. The vast
majority of individuals experience headaches during
their lives. The prevalence of headache in the popula-
tion differs from one study to another, partly due to
different de®nitions and study set-ups. Usually such
prevalence is estimated as . 70%, sometimes as high as
97% [13]. One of the commonly mentioned causes of
headaches is increment in blood pressure in arterial
hypertension. However, arterial hypertension is also
quite common, being reported in at least one-quarter of
the general population [14]. Thus, there must be
considerable overlap in the prevalence of headache and
442 Journal of Hypertension 2000, Vol 18 No 4
hypertension in the general population. However, there
are reports that there is a signi®cant correlation be-
tween blood pressure levels and headache in the
population [4,6,9]. Furthermore, some authors claimed
that the treatment of hypertension may reduce the
frequency of headache [8,9,11]. However, it was also
reported that differences in prevalence of headache
between normotensive and hypertensive subjects dis-
appeared after correction for awareness of hypertension
[1,7].
Our study was not designed to verify the hypothesis
that hypertensive patients suffer more often from head-
aches than normotensive patients. Nevertheless, the
fact that 30% of hypertensive patients experienced
headache during ABPM seems to indicate a high
frequency of headache in this group. The percentage of
patients experiencing headache was fairly similar in all
studied subgroups (non-medicated and/or with ABPM
daytime blood pressure > 135/85 mmHg, as well as
subjects treated with different classes of drugs,
Table 2). On the other hand, blood pressure levels in
the group of patients experiencing headache during
ABPM were not signi®cantly different from those with-
out headache on that day (Table 1). Therefore, a
control group of normotensive individuals should be
investigated under the same conditions, before drawing
®nal conclusions.
The aim of our study was to establish whether head-
ache in patients with mild to moderate hypertension is
associated with simultaneous blood pressure elevation.
Our results seem to indicate that blood pressure eleva-
tions are generally not associated with headaches in
stage 1±2 hypertensive patients because (i) mean blood
pressure values from headache periods were not sig-
ni®cantly higher than those from headache-free periods
(Table 3); (ii) blood pressure values directly preceding
the pain were not signi®cantly different from values at
the beginning of headache (Table 4); usually the differ-
ences of 1 h blood pressure means from the headache
onset and 1 h means from the period directly prior to
headache were not marked, rarely exceeding 10 mmHg;
and (iii) in the vast majority of hypertensives, the
maximal blood pressure values were recorded outside
reported headache periods (Fig. 2). Moreover, in some
instances, patients who disclosed maximal ABPM va-
lues during headache had relatively high blood pres-
sure, i.e. > 180/110 mmHg (Fig. 1a,b).
On average, maximal headache-free blood pressure
values were signi®cantly higher than maximal values
from headache periods (Table 5). This may be ex-
plained by the fact that headache periods were gen-
erally much shorter (median 3 h) than analysed
headache-free periods. If the assumption that blood
pressure levels seen in mild to moderate hypertension
exert no direct in¯uence on headache is valid, the
chance to ®nd the maximal blood pressure values will
be greater in the longer time period (headache-free
period) than in the shorter time period (headache
period).
Headache as a symptom of arterial hypertension is well
known both to physicians and hypertensive patients.
Thus, there is always a risk that they would attribute
any occurring headache to high blood pressure. Such an
association is well documented in hypertensive ence-
phalopathy [15±18] and pheochromocytoma [19±23].
However, this fact cannot serve as a proof that head-
ache is generally caused by simultaneous elevation of
blood pressure in patients with mild to moderate hyper-
tension.
Another explanation of greater prevalence of headache
among hypertensive patients, in comparison to normo-
tensive subjects, might be a common predisposition to
both arterial hypertension and headache. There are
reports suggesting higher co-morbidity of migraine and
hypertension than just due to chance [10,13,24,25].
It may also be probable that headache is a cause and
not a symptom of increased blood pressure. Headache,
especially more severe ones, may cause a non-speci®c
activation of the sympathetic nervous system resulting
in blood pressure increment [26]. On the other hand,
there is a possibility that headache may lead to
diminished patient activity, and, as a consequence,
relatively lower blood pressure levels assessed with
ABPM. This would especially pertain to patients who
assume a supine position during the headache period.
However, we obviated this type of error in our study by
excluding from further analysis periods when patients
maintained a supine position during ABPM. There is
still the theoretical possibility that the patients would
avoid physical activity during the analysed periods of
headache. This does not seem to be a source of signi®-
cant error, since the analysis of collected questionnaires
revealed a sedentary lifestyle in the vast majority of
patients.
The in¯uence of anti-hypertensive treatment on head-
ache may be manifold. For example, drugs such as â-
blockers or calcium antagonists, known to be effective
in arterial hypertension, are also successfully used in
treatment of so-called vascular headaches [27]. Thus,
the fact that frequency of headache decreased in a
group of effectively treated hypertensives does not
necessarily imply a causal relationship between decre-
ment in blood pressure and lower frequency of head-
aches in all hypertensive patients. Therefore,
mechanisms of in¯uencing headache by anti-hyper-
tensive treatment other than blood pressure reduction
should also be taken into consideration.

One must also remember that low blood pressure may
be responsible for headache in treated hypertensives
[6,28] (Fig. 1d).
Headache is frequently reported as a side-effect of
treatment with anti-hypertensive agents. However,
there are no generally accepted criteria for classifying
headache as being drug-induced. Therefore, the role of
medication as a causative factor of headache may be
over-estimated by linking different types of headache
with given drug treatment. In our material, none of the
patients linked headache with receiving anti-hyper-
tensive treatment. In addition, there were no signi®cant
differences between the percentages of subjects with
headache during ABPM in the non-medicated group
when compared with any of ®ve subgroups constructed
on the basis of treatment with one of the drug classes ±
diuretics, ACE inhibitors, â-blockers, calcium antago-
nists and nitrates. Since it was impossible to de®nitely
rule out the in¯uence of drugs on headache in indivi-
dual patients, we analysed blood pressure changes in a
subgroup of non-medicated subjects who experienced
headache during ABPM. The number of patients was
limited in this subgroup (n ˆ 15) since we did not
discontinue previous hypertensive medication in our
study. Therefore, we performed ®ve analyses on groups
of subjects with headache during ABPM, subtracting
each time the subjects treated with one drug type (i.e.
all subjects except those treated with diuretics, all
subjects except those treated with â-blockers, etc).
Using this approach, we obtained similar results to
those obtained for the entire studied group or non-
medicated subgroup (Tables 3±5) ± no causal relation-
ship seemed to exist between blood pressure elevation
and headache.
Not all the patients labelled as hypertensives, recruited
to our study on the basis of increased of®ce blood
pressure values, disclosed hypertensive values in
ABPM [12]. Therefore, we performed the same analysis
on a subgroup restricted to patients with average day-
time blood pressure > 135/85 mmHg [12]. We did not
®nd any signi®cant relationship between blood pressure
increment and headache in this subgroup either
(Tables 3±5). The same pertained to the most homo-
genous subgroup of our study: non-medicated patients
with daytime means of blood pressure > 135/85 mmHg
(Tables 3±5).
In conclusion, we did not ®nd that headache was
generally associated with simultaneous elevations in
blood pressure up to 180/110 mmHg. The blood pres-
sure threshold for developing headache would probably
differ from one patient to another. Thus, one cannot
exclude the possibility that in individual patients, head-
ache might be caused by less marked increments in
blood pressure. The direct mechanisms of headache in
Blood pressure and headache Kruszewski et al. 443
hypertension, as well as the relation between incre-
ments in blood pressure above 180/110 mmHg and
headache, need further investigations. However, for
ethical reasons, these will be more dif®cult to perform.
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