Your BP may be high even when you feel normal: Why you must begin screening at 18

A 38-year-old software engineer from Bengaluru considered himself healthy. He rarely fell sick, exercised moderately and had never experienced severe headaches or dizziness. During a routine health check organised at his workplace, however, his blood pressure was measured at 156/96 mmHg (normal being 120/80 mmHg). Assuming it was simply stress from an important meeting, he ignored the result. When his physician advised him to monitor his blood pressure at home for a week, the readings remained consistently high. Further evaluation revealed early changes in his heart and kidneys — damage that had been developing quietly for years despite the lack of obvious symptoms.

Rajesh’s story is far from unusual. Across India, millions of people unknowingly live with hypertension because they continue to believe a dangerous myth: if I feel fine, I must be healthy. The most significant knowledge gap in the Indian context is the belief that high blood pressure triggers obvious distress, such as nosebleeds or intense headaches. While these occur in emergencies, millions of Indians live with Stage 1 hypertension (blood pressure readings between 130–139 mmHg systolic or 80–89 mmHg diastolic) and feel remarkably energetic.

Blood pressure is the measurement of the force exerted against your arterial walls. When this pressure remains chronically elevated, the arteries become stiffer and thicker to withstand the force. Because this process is gradual and occurs at a cellular level, your brain often adapts to the “new normal,” leaving you unaware of the strain on your heart and kidneys. This is particularly concerning for the youth. Hypertension affects 12.1 per cent of young Indians, who face a heightened risk of premature cardiovascular events and impaired productivity.

Subtle signals we often dismiss

While hypertension is asymptomatic in the traditional sense, it often leaves subtle physiological signals that modern Indians frequently dismiss as signs of ageing or a busy lifestyle. Peer-reviewed clinical observations suggest we should be more attentive to these overlooked indicators:

● Nocturia (Waking up to urinate): Frequent nighttime urination can be a sign that high blood pressure is straining the kidneys, forcing them to work overtime during rest.

● Pulsatile Tinnitus: A rhythmic thumping or “whoosh” sound in the ears that keeps pace with your heartbeat, often caused by turbulent blood flow through narrowed arteries.

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● The “Heavy” Neck or Shoulders: Chronic tension at the base of the skull or on top of the shoulders can be a secondary response to vascular strain, rather than just poor posture.

● Unexplained Sleep Disturbances: Research in the Journal of Clinical Sleep Medicine indicates a strong correlation between hypertension and fragmented sleep.

● Subconjunctival Haemorrhage: A painless red spot in the eye can be a visual cue that small, fragile capillaries have ruptured due to high systemic pressure.

What triggers high blood pressure?

In India, excessive sodium intake remains one of the biggest culprits, with salt hidden not only in traditional foods such as pickles and papads but also in packaged “diet” snacks, ready-to-eat meals and fast food. Rising rates of obesity, increasingly sedentary lifestyles and chronic emotional stress further compound the problem. A clinical analysis of more than 8,600 Indian patients found that excess salt intake (39%) was the most common risk factor for hypertension, followed by obesity (32.9%), a sedentary lifestyle (28.6%), and emotional stress (20.7%). Adding to these lifestyle challenges is the South Asian phenotype, which makes Indians more susceptible to strokes and heart attacks at comparatively lower blood pressure levels than many Western populations.

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Masked hypertension: Trust the data, not the feeling

We are seeing a rise in masked hypertension, where blood pressure appears normal in a clinic but spikes during work or sleep. Use the Rule of Three. Measure your BP at home at the same time for three consecutive days. If the average is consistently above 135/85 mmHg, your body is telling you the truth that your symptoms aren’t. A 24-hour ambulatory blood pressure monitoring test will give valuable data on the blood pressure readings throughout the day and night. This not only helps in diagnosing hypertension, but also helps in identifying specific triggers and managing hypertension.

When to measure your BP?

The three most useful time slots to measure blood pressure are as follows:

1. Early morning (most important)

Measure within one hour of waking up.

Before breakfast.

Before taking your blood pressure medications.

2. Midday (optional, but useful in selected patients)

Between 12–3 PM.

Before lunch or at least 2 hours after eating.

Useful in patients with highly variable or resistant BP

3. Evening

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Measure before dinner or at least 2 hours after dinner.

Before taking evening antihypertensive medication (if prescribed).

It is also advisable to avoid drinking any sort of caffeine, alcohol and exercise for at least 30 minutes before readings. Similarly, it is important to take two or three readings and average them out, and do this for seven consecutive days. When there is persistently high blood pressure in the early morning (morning hypertension), it is important to screen for the following conditions:

Inadequate 24-hour blood pressure control (most common)

Exaggerated morning blood pressure surge

Nocturnal hypertension

Obstructive sleep apnea (OSA)

High dietary sodium intake or fluid retention

Secondary hypertension from possible kidney disease.

When should Indians begin screening for BP?

Indians should begin monitoring their blood pressure from the age of 18, even if they are healthy.

Ages 18–39: If your blood pressure is below 120/80 mmHg and you have no risk factors, get it checked at least once a year. If your readings are 120–139/80–89 mmHg or you have risk factors such as obesity or a family history of hypertension, monitor it more frequently — typically every three to six months, or as advised by your doctor.

Age 40 and above: Have your blood pressure checked every six to 12 months, even if previous readings have been normal. People with hypertension, diabetes, chronic kidney disease (CKD), obesity, cardiovascular disease, or during pregnancy: Follow your doctor’s advice, which may include regular home blood pressure monitoring in addition to clinic visits.

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Fix your exercise slot

Regular physical activity is one of the most effective non-pharmacological ways to lower blood pressure. Do aerobic exercises like brisk walking, cycling, swimming, jogging and dancing. About 150–300 minutes/week of moderate-intensity activity (brisk walking) or 75–150 minutes/week of vigorous-intensity activity is recommended. Go for strength training thrice a week; I recommend weights, dumbbells, resistance bands, and bodyweight exercises (push-ups, squats, lunges). Do isometric exercises, which involve sustained muscle contractions without joint movement, like wall sits and handgrip exercises. For flexibility and balance training, opt for yoga and tai chi.

(The author is a senior consultant and Director, Heart Transplant Programme, Narayana Institute of Cardiac Sciences, Bengaluru)