Hypertensive crisis: severe occipital headache, palpitations, stiff neck, sweating, nausea - emergency, hold and report immediately.
Before you read
Test yourself first: 3 questions
Question 1 of 3
A client is being discharged on phenelzine, an MAOI. Which statement indicates the client understands the teaching about dietary precautions?
Answer: A. Correct understanding of MAOI teaching is reflected by avoiding tyramine-containing foods such as aged cheese, smoked/cured meats, fermented soy products, and tap/draft beer to prevent hypertensive crisis. Stating that aged and fermented foods must be avoided indicates correct learning. Eating extra aged cheese or unlimited cured meats is unsafe.
Question 2 of 3
A nurse is teaching a client about phenelzine, an MAOI. Which over-the-counter medication should the nurse instruct the client to avoid?
Answer: A. Decongestants containing pseudoephedrine or phenylephrine are sympathomimetics and, combined with an MAOI, can precipitate a hypertensive crisis. Clients on MAOIs must check with the provider before any OTC cold remedy. Plain acetaminophen, calcium, and stool softeners are generally acceptable.
Question 3 of 3
A client taking phenelzine, a monoamine oxidase inhibitor (MAOI), reports a severe throbbing headache, neck stiffness, and palpitations after eating aged cheese. Which complication should the nurse suspect?
Answer: B. Aged cheeses are high in tyramine. When combined with an MAOI, tyramine cannot be metabolized and causes a hypertensive crisis, marked by severe headache, neck stiffness, palpitations, and dangerously elevated blood pressure. This is a medical emergency.
Keep the streak going with more questions like these, each with a full rationale.
What is phenelzine?
It blocks the enzyme that breaks down tyramine, so eating tyramine-rich foods can trigger a hypertensive crisis. MAOIs are a high-alert teaching priority on the NCLEX. Memory aid: avoid aged, fermented, smoked, and pickled foods.
Key points to remember
- Tyramine-rich foods (aged cheese, cured/smoked meats, fermented soy, draft beer, red wine, pickled/overripe foods) can cause hypertensive crisis.
- Combining with SSRIs, SNRIs, TCAs, meperidine, or sympathomimetics risks serotonin syndrome or hypertensive crisis.
- A 14-day washout is required between an MAOI and other serotonergic antidepressants (both directions).
- Effect on mood takes 2-4 weeks; orthostatic hypotension is a common early side effect.
- OTC decongestants, cold remedies, and stimulants must be avoided.
- Carries the antidepressant suicide black box warning.
Nursing priorities
- Teach the tyramine-restricted diet thoroughly and verify understanding.
- Monitor blood pressure and assess for orthostatic hypotension.
- Review all prescription, OTC, and herbal products for interactions before administering.
- Ensure adequate washout period when switching antidepressants.
- Assess for suicidal ideation early in therapy.
Patient teaching
- Strictly avoid tyramine-rich foods: aged cheese, cured/smoked/processed meats, fermented soy, draft beer, red wine, pickled or overripe foods.
- Do not take any OTC cold, cough, or decongestant products without provider approval.
- Report severe headache, palpitations, or neck stiffness immediately - it may be a hypertensive crisis.
- Change positions slowly to avoid dizziness from low blood pressure.
Red flags: report now
- Hypertensive crisis: severe occipital headache, palpitations, stiff neck, sweating, nausea - emergency, hold and report immediately.
- Serotonin syndrome with concurrent serotonergic drugs.
- Never combine with SSRIs/SNRIs/TCAs/meperidine or give without a 14-day washout.
- New or worsening suicidal thoughts.
References
Clinical references for this topic
