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Question: I recently had a high blood pressure reading at my annual physical, but my doctor didn't start me on medication. What can I do to stay on top of this? Should I be checking my blood pressure at home?
Doctors call hypertension the "silent killer." That's because it can cause serious medical problems, but people with high blood pressure often feel perfectly fine.
It's scary, right? Without treatment, hypertension can put people at risk for heart attacks, strokes and kidney disease. It's also extremely common, affecting an estimated 31% of adults worldwide. Many of my patients are walking around with this deadly condition and have no idea until they come in for a primary care appointment.
That's why it's important that you get your blood pressure checked regularly. The U.S. Preventive Services Task Force — a nonpartisan government body that issues guidelines about preventive care — suggests that all adults over 18 get screened for hypertension with a blood pressure check in a doctor's office. (They don't make strong recommendations about how often, but say it's reasonable that everyone over age 40 do this at least once a year.)
But ironically, checking your blood pressure in a doctor's office is not always the best way to diagnose hypertension. Getting the diagnosis right is trickier than you might imagine.
Let's break down how to think about this deceptively complex condition.
Hypertension can be tough to diagnose
Although in-office measurements are recommended to screen for hypertension — that means identifying who's at-risk — actually diagnosing it is another matter.
That's because hypertension is defined by repeated high blood pressure readings, not just one. It's normal for your blood pressure to fluctuate throughout the day.
"Blood pressures are very dynamic measurements," said Dr. Ryan McCormick, a family physician in New Jersey who writes the newsletter Examined. "They go up and down throughout the day, minute by minute."
When you're getting your blood pressure checked in a doctor's office or emergency room, it's often high because of stress or pain. This can be a normal physiologic response.
"You're there under the spotlight," McCormick said. "It can be very anxiety-provoking."
This phenomenon has a name: white coat hypertension, meaning the doctor's white coat makes you nervous and raises your blood pressure. People who frequently get white coat hypertension are at higher risk for developing true hypertension, but they're not the same thing.
That's why you might have been told that you had an elevated reading but your doctor didn't immediately recommend medication.
That high blood pressure measurement was only one data point. To confidently diagnose hypertension, your doctor will need more.
Checking at home
Checking your blood pressure at home can help add valuable data to an isolated blood pressure reading at a once-a-year doctor's visit.
Not everybody needs to run out and buy a blood pressure cuff. But if you've had a high or borderline reading in a health care setting, it might be worth it to monitor occasionally at home.
In 2025, the American College of Cardiology issued updated hypertension guidelines, and they note that home readings enhance "the accuracy and precision for detecting a patient's true and usual BP levels."
McCormick says if he sees a patient with an elevated in-office reading, he'll recommend they check their blood pressure at home a few times a week. Then, when they return to see him again, together they'll review the data and decide whether or not the patient has a true diagnosis.
"That's the luxury you have as a family physician," McCormick told me. "You're not just seeing them in the ER … You have continuity, and ideally you have home monitoring."
Proper technique
Whether you're getting your blood pressure checked at a doctor's office or doing it at home, proper technique is key.
Using a cuff that's too small for your arm, for example, can cause systolic blood pressure readings that are off by almost 20 points. (That's the top number, which reflects your blood pressure while your heart is contracting.)
The American Heart Association recommends several steps to make sure your blood pressure reading is as accurate as possible.
First, it recommends avoiding caffeine, exercise or smoking for at least 30 minutes before checking your blood pressure. And make sure you go pee! A full bladder can definitely raise your blood pressure.
You should also rest quietly for at least five minutes before the test. This is one mistake I often see in my own practice — people are rushing to their appointment and aren't given adequate time to calm down. You should be seated with your feet on the floor and your back supported against a chair.
And no talking, please! Neither you nor the person checking your blood pressure should be making chit-chat during the measurement.
Which cuff is best?
If you're buying a cuff to use at home, there are lots on the market. Several cuffs from Omron have been validated in scientific studies, as have models from Microlife. If you're unsure which brand to use, ask your doctor.
It's important to use a properly sized cuff, which can be tricky to determine. Guidelines recommend a cuff bladder — that's the part that inflates when it's squeezing your arm — that's 75% to 100% the length of your arm circumference. The whole thing should comfortably wrap around your upper arm about one and a half times. People with a very large arm circumference may need cone-shaped cuffs rather than the cylindrical cuffs you typically see.
The cuff should be placed on bare skin, so wear short sleeves when you go to the doctor. And when you're taking measurements, your arm should be supported at the level of your heart, ideally resting on a table.
I wouldn't suggest using a wrist cuff. The cuff needs to encircle your upper arm to get a good reading. And so-called "cuffless" blood pressure monitoring techniques — like, say, using your Apple Watch to estimate your blood pressure — are not accurate, and doctors do not currently recommend using them.
When to start medication
Over the last decade, doctors have redefined hypertension.
The change comes in response to a growing body of research that shows lower blood pressure targets help prevent serious cardiovascular events like heart attacks or strokes. So this is how the American College of Cardiology defines things:
- Normal blood pressure: Below 120/80
- Elevated reading = 120-129/80
- Hypertension = 130/80 or above
I'll typically recommend that a patient start a medication if they've had multiple blood pressure readings in the hypertension range over at least one month. The goal of treatment is to get their blood pressure below 130/80.
Sometimes, a new patient will have one very high reading. In that scenario, I'll repeat the blood pressure measurement to make sure it's accurate — using proper technique! If I feel confident it's truly high, I'll prescribe medication right away, even without multiple blood pressure measurements. In particular, I'll do this if I'm worried it will be challenging for the patient to return for another blood pressure check.
If you have several readings above 130/80 at home, you should go see your doctor to talk about treatment options.
Treatment goals depend on your age
In older patients, I sometimes back off on aggressive treatment for high blood pressure. Many doctors recommend that blood pressure values run a little higher in the elderly, which is supported by guidelines from primary care organizations like the American College of Physicians and American Academy of Family Physicians.
That's because the harms of intense blood pressure treatment can sometimes outweigh the benefits. Blood pressure medications can sometimes make people feel lightheaded, which is usually less pronounced in younger patients. But in older folks, lightheadedness can lead to a fall, which can have serious consequences like a broken bone or a head injury.
Blood pressure medications can also cause electrolyte abnormalities, which are more likely to be life-threatening in an older patient.
There are many good reasons to intensively treat high blood pressure, but the benefits accumulate over many years. For a patient who's 40, aggressive hypertension treatment can prevent a heart attack or stroke at age 60. But for a patient who's 95 and probably has a life expectancy under 10 years, medication side effects can cause immediate harm, while the long-term benefits are less clear.
Prevention is the best medicine
Regular exercise and cutting back on alcohol can help reduce your risk of developing hypertension.
Hypertension "is informed and influenced by so many things, like mental status, mood, stress levels, diet, exercise," said McCormick, the family physician.
When it comes to diet, the Dietary Approaches to Stop Hypertension, or DASH, eating plan is research-backed and effective. It emphasizes vegetables, fruits, fiber and whole grains.
While reducing sodium intake can help, you don't need to go too crazy cutting out all salt. I've found it can sometimes backfire. I've seen my patients give up on home cooking if their food tastes too bland! Instead, I recommend cutting back on ultra-processed foods and getting into the habit of making delicious meals at home using fresh ingredients.
Stress reduction is also key (which is easier said than done, of course). There are some proactive stress management techniques that the ACC endorses, including transcendental meditation and yoga.
But if you're diagnosed with hypertension even after doing all of the above, don't be too hard on yourself. Hypertension is a strongly genetic disease. Medications are a key tool in helping get your blood pressure down to healthy levels.
Dr. Mara Gordon is a family physician in Camden, N.J. She writes the newsletter Your Doctor Friend.
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