Headache localization associated with hypertension risk in emergency department patients with elevated blood pressure

Patients presenting to emergency departments (ED) with headache and elevated blood pressure pose diagnostic challenges. The relationship between headache localization patterns and subsequent hypertension diagnosis remains poorly understood. This retrospective observational study examined 822 patients with elevated blood pressure (≥ 140/90 mmHg) but no prior hypertension diagnosis who presented to a state hospital ED between January 2018 and May 2024, all of whom underwent comprehensive cardiovascular evaluation including electrocardiography, echocardiography, and laboratory investigations. 12 month follow-up data were available for all included patients. Headache localization was classified as posterior, anterior, lateralized, holocephalic, or orbital/facial. Multivariable logistic regression analysis was performed to identify factors independently associated with hypertension diagnosis during follow-up. Normality of continuous variables was assessed using the Kolmogorov–Smirnov test prior to parametric testing. During 12 month follow-up, 51.5% (423/822) of patients received a hypertension diagnosis, with significant variation by headache location: posterior 64.6%, holocephalic 60.5%, orbital/facial 56.7%, anterior 44.2%, and lateralized 31.0%. Multivariable analysis identified posterior headache as the strongest independent correlate of hypertension diagnosis (adjusted OR 2.45, 95% CI 1.64–3.67, p < 0.001), followed by holocephalic (OR 1.89, 95% CI 1.18–3.02, p = 0.012) and orbital/facial patterns (OR 1.52, 95% CI 1.01–2.29, p = 0.045). The model demonstrated good discrimination (AUC 0.78). Lateralized headache was independently associated with a lower likelihood of hypertension diagnosis (OR 0.38, 95% CI 0.25–0.58, p < 0.001). In this selected population of ED patients undergoing comprehensive cardiovascular evaluation, headache localization patterns were independently associated with subsequent hypertension diagnosis. The findings more likely represent identification of pre-existing undiagnosed hypertension than true incident disease, as evidenced by ECG markers of left ventricular hypertrophy at baseline. These findings require prospective validation before clinical application.