Health & Healing from the Pain Healers Alliance

Sunday, January 25, 2026

STRESSFUL BLOOD PRESSURE READINGS

Why Are My Numbers Still So Erratic—Even on Medication?

By: Lennard M. Goetze, Ed.D

Few things are more frustrating—and frightening—than watching your blood pressure spike despite doing “everything right.” You take your medications faithfully. You follow your doctor’s instructions. And yet, on certain days, your home monitor flashes numbers like 180/90, leaving you confused, anxious, and wondering what you’re doing wrong.

The short answer is: you may not be doing anything wrong at all.
The longer answer is that blood pressure is far more complex—and far more reactive—than most people are ever told.

This article explains why blood pressure can remain erratic even on medications like lisinopril and amlodipine, what factors commonly interfere with control, and what practical steps you can take—especially around sleep—to regain stability.

Blood Pressure Is Not a Fixed Number

One of the most common misconceptions about blood pressure is that it should behave like a thermostat—steady, predictable, and consistent. In reality, blood pressure is a dynamic, moment-to-moment physiological response, influenced by:

· Stress and emotional state

· Sleep quality and breathing patterns

· Pain or inflammation

· Hormones

· Hydration and electrolytes

· Blood vessel stiffness

· Nervous system activity

· Timing and method of measurement

A reading of 180/90 does not automatically mean your medication has “failed.” It means your body is responding to something—sometimes several things at once.

What Your Medications Are (and Aren’t) Doing

Lisinopril

Lisinopril is an ACE inhibitor. It works by blocking a hormone system (the renin-angiotensin-aldosterone system) that tightens blood vessels and retains sodium. This lowers pressure over time and protects the heart and kidneys.

Amlodipine

Amlodipine is a calcium channel blocker. It relaxes the muscular walls of blood vessels, improving blood flow and reducing resistance.

Together, these medications are commonly prescribed and effective—but they do not override every biological trigger of blood pressure spikes. They also behave differently depending on genetics, vascular health, metabolism, stress load, and sleep quality.

Why Blood Pressure Still Spikes on Medication

1. Stress and the Nervous System

Stress is not just emotional—it is physiological. When the brain perceives threat (work pressure, health anxiety, conflict), the sympathetic nervous system releases adrenaline and cortisol. This can temporarily overpower medications, tightening blood vessels and accelerating heart rate.

Even anticipating a blood pressure reading can raise blood pressure itself—a phenomenon known as the home white-coat effect.

2. Measurement Errors (Extremely Common)

Many alarming readings are not true resting values.

Frequent mistakes include:

· Measuring immediately after activity

· Sitting with legs crossed or unsupported

· Arm not positioned at heart level

· Talking or scrolling during measurement

· Using the wrong cuff size

· Taking repeated readings while anxious

Blood pressure should be measured after five minutes of quiet rest, seated, feet flat, back supported, arm relaxed.

3. Medication Timing vs. Circadian Surges

Blood pressure follows a daily biological rhythm. Some people experience early-morning surges or late-day “breakthrough” elevations when medication levels dip before the next dose. This often requires timing adjustments, not stronger drugs.

4. Salt Sensitivity and Fluid Balance

Some individuals are highly salt-sensitive. Even moderate sodium intake—especially from restaurant meals, sauces, or soups—can cause significant blood pressure spikes. Dehydration followed by fluid retention can compound the problem.

5. Vascular Stiffness

Medications lower pressure, but they do not fully reverse arterial stiffness, which increases with age, inflammation, and metabolic stress. This often causes isolated systolic spikes even when average readings appear controlled.

6. Pain, Hormones, and Inflammation

Chronic pain, untreated inflammation, thyroid imbalance, and cortisol dysregulation can all elevate blood pressure—sometimes dramatically—despite medication compliance.

PART 2: SLEEP- The Missing Link in Blood Pressure Control

If medications are the tools, sleep is the foundation. Yet sleep is one of the most overlooked contributors to persistent or erratic hypertension. During healthy sleep, blood pressure normally drops by 10–20%, allowing the heart and blood vessels to recover. This process—called nocturnal dipping—is essential for cardiovascular health.

When sleep is disrupted:

· Cortisol and adrenaline remain elevated

· The nervous system stays in fight-or-flight mode

· Blood vessels remain constricted

· Blood pressure fails to reset overnight

Over time, this leads to persistent elevation and unpredictable spikes.

What Is Circadian Rhythm?

The circadian rhythm is the body’s internal 24-hour clock. It regulates:

· Sleep and wake cycles

· Blood pressure patterns

· Hormone release

· Body temperature

· Metabolism

Blood pressure normally:

· Drops during deep sleep

· Rises sharply in early morning

· Stabilizes during the day

· Falls again at night

Disruptions—poor sleep, late-night screen use, shift work, stress, or sleep disorders—can cause:

· Morning blood pressure surges

· Loss of nighttime dipping

· Increased cardiovascular risk

Snoring and Sleep Apnea: A Critical Connection

Chronic snoring is often dismissed, but it may signal obstructive sleep apnea (OSA)—a major, underdiagnosed cause of resistant hypertension.

What Does “Apnea” Mean?

Apnea means “without breath.” In obstructive sleep apnea:

· The airway collapses during sleep

· Breathing stops for 10 seconds or longer

· Oxygen levels fall

· The brain triggers a stress response to resume breathing

This cycle can repeat dozens or hundreds of times per night, often without conscious awareness.

What Happens When Breathing Stops?

Each pause in breathing causes:

· Oxygen deprivation

· A surge in adrenaline

· Sudden spikes in heart rate and blood pressure

These repeated stress responses overwhelm the cardiovascular system, preventing restorative sleep and undermining blood pressure control—even with medication.

Sleep Apnea and Blood Pressure

Sleep apnea is strongly linked to:

· Resistant hypertension

· Morning blood pressure spikes

· Loss of nighttime dipping

· Increased risk of heart attack and stroke

Many patients with sleep apnea:

· Require multiple BP medications

· Experience erratic readings

· Wake feeling unrefreshed

· Have morning headaches or brain fog

When to Get Checked

Consider evaluation if you experience:

· Loud, chronic snoring

· Pauses in breathing or gasping at night

· Excessive daytime fatigue

· Morning headaches

· Blood pressure that remains high despite treatment

Diagnosis typically involves a sleep study, either at home or in a lab.

The Takeaway

Blood pressure is not just a number—it is a reflection of how your nervous system, blood vessels, hormones, and sleep are functioning together. Persistent or erratic readings do not mean failure. They signal the need for deeper evaluation and individualized care—especially around sleep and breathing.

For many people, addressing sleep quality or untreated sleep apnea becomes the turning point where blood pressure finally stabilizes. Sometimes, the most powerful intervention doesn’t come in a pill—it comes from restoring the body’s ability to breathe, recover, and reset each night.

This article is for educational purposes only and does not replace individualized medical care. Always consult your healthcare provider regarding persistent high blood pressure or medication changes.

PART 3 — STRESS, CORTISOL & THE NERVOUS SYSTEM

Why Your Body May Be Holding Onto High Blood Pressure

When blood pressure remains stubborn or erratic despite medication, sleep optimization, and good intentions, the missing driver is often the nervous system. Stress is not merely emotional—it is biological. And when stress becomes chronic, it can quietly reprogram how the body regulates blood pressure.

The Autonomic Nervous System: The Hidden Regulator

Blood pressure is governed largely by the autonomic nervous system (ANS)—the system that controls involuntary functions such as heart rate, blood vessel tone, digestion, and breathing. The ANS has two main branches:

Sympathetic nervous system – the “fight or flight” response
Parasympathetic nervous system – the “rest and recover” response

Healthy blood pressure depends on a dynamic balance between these two states. Chronic stress shifts that balance heavily toward sympathetic dominance.

What Chronic Stress Does to Blood Pressure

When the brain perceives ongoing stress—work pressure, financial worry, caregiving strain, unresolved trauma, health anxiety—it repeatedly activates the sympathetic nervous system. This causes:

Constriction of blood vessels
Increased heart rate
Release of stress hormones
Reduced ability of vessels to relax

Over time, the body begins to treat this elevated state as “normal,” resulting in persistent or volatile blood pressure elevations.

Cortisol: The Long-Acting Stress Hormone

While adrenaline causes short bursts of pressure spikes, cortisol is responsible for sustained elevation.

Cortisol:

Increases blood sugar
Promotes sodium and fluid retention
Amplifies vascular sensitivity to stress
Interferes with nighttime blood pressure dipping

When cortisol remains elevated—especially in the evening—blood pressure fails to reset during sleep, leading to morning surges and daytime instability.

Stress and “Medication Resistance”

This is one of the least discussed truths in hypertension care:
Stress hormones can blunt the effectiveness of blood pressure medications.

Medications act on vessels and fluid balance, but they do not fully suppress:

Stress signaling from the brain
Cortisol-driven sodium retention
Repeated adrenaline surges

As a result, patients may be labeled “resistant” or “difficult to control,” when the real issue is an overactivated nervous system—not inadequate medication.

Why Blood Pressure Spikes Seem Random

Stress-related blood pressure spikes often feel unpredictable because:

Stressors may be subconscious
Cortisol patterns vary day to day
Poor sleep amplifies stress response
Repeated BP checking increases anxiety

This creates a feedback loop:

Stress raises blood pressure
High readings create fear
Fear triggers more stress
Blood pressure rises further

Breaking this cycle requires addressing the nervous system—not just the numbers.

The Role of Breathing and Vagus Nerve Tone

The vagus nerve is the primary driver of parasympathetic (calming) activity. When vagal tone is low, blood pressure remains elevated even at rest.

Slow, controlled breathing directly stimulates the vagus nerve, leading to:

Reduced heart rate
Improved vessel relaxation
Lower systolic pressure
Reduced cortisol output

This is not psychological—it is neurological physiology.

Stress Is Not Weakness—It Is Load

It is critical to understand: stress-related hypertension is not a failure of willpower or character. It is the cumulative effect of physiological load over time.

Sources of load include:

Chronic work pressure
Caregiving responsibilities
Past trauma
Long-term sleep deprivation
Ongoing health anxiety
Persistent inflammation or pain

The body does not distinguish between “emotional” and “physical” threats—it responds to both the same way.

What You Can Do to Reset the System

1. Normalize Stress as a Medical Factor

Acknowledge stress as a legitimate contributor to blood pressure—not an afterthought.

2. Practice Nervous System Regulation Daily

Even brief interventions help:

Slow diaphragmatic breathing (5–10 minutes)
Short walks in nature
Gentle stretching or yoga
Mindfulness or body-based relaxation

Consistency matters more than intensity.

3. Stop Chasing Numbers

Repeated checking increases sympathetic activation. Focus on patterns, not momentary spikes.

4. Support Sleep and Recovery

Sleep and stress are inseparable. Poor sleep amplifies cortisol; high cortisol disrupts sleep.

5. Discuss Stress Physiology With Your Clinician

Ask about:

Cortisol patterns
Heart rate variability
Autonomic balance
Medication timing adjustments

The Takeaway

Blood pressure control is not just about blood vessels—it is about how the brain, hormones, and nervous system communicate with the cardiovascular system. When stress becomes chronic, the body forgets how to relax. Medications can help, but they cannot replace the body’s need for safety, recovery, and regulation. Stability returns not by forcing the numbers down—but by teaching the nervous system that it is safe to let go.

References

1. Brook, R. D., Appel, L. J., Rubenfire, M., Ogedegbe, G., Bisognano, J. D., Elliott, W. J., … Rajagopalan, S. (2013). Beyond medications and diet: Alternative approaches to lowering blood pressure. Hypertension, 61(6), 1360–1383. https://doi.org/10.1161/HYP.0b013e318293645f

2. Calhoun, D. A., Jones, D., Textor, S., Goff, D. C., Murphy, T. P., Toto, R. D., … White, A. (2008). Resistant hypertension: Diagnosis, evaluation, and treatment. Hypertension, 51(6), 1403–1419. https://doi.org/10.1161/HYPERTENSIONAHA.108.189141

3. Fagard, R. H., & Thijs, L. (2007). Prognostic significance of ambulatory blood pressure monitoring. Current Hypertension Reports, 9(4), 266–272. https://doi.org/10.1007/s11906-007-0049-8

4. Gangwisch, J. E., Feskanich, D., Malaspina, D., Shen, S., & Forman, J. P. (2013). Sleep duration and risk for hypertension in women: Results from the Nurses’ Health Study. American Journal of Hypertension, 26(7), 903–911. https://doi.org/10.1093/ajh/hpt044

5. Javaheri, S., & Redline, S. (2017). Insomnia and risk of cardiovascular disease. Chest, 152(2), 435–444. https://doi.org/10.1016/j.chest.2017.01.026

6. Kario, K. (2010). Morning surge in blood pressure and cardiovascular risk. Hypertension, 56(5), 765–773. https://doi.org/10.1161/HYPERTENSIONAHA.110.157149

7. McEwen, B. S. (2007). Physiology and neurobiology of stress and adaptation: Central role of the brain. Physiological Reviews, 87(3), 873–904. https://doi.org/10.1152/physrev.00041.2006

8. Pedrosa, R. P., Drager, L. F., Gonzaga, C. C., Sousa, M. G., de Paula, L. K., Amaro, A. C., … Lorenzi-Filho, G. (2011). Obstructive sleep apnea: The most common secondary cause of hypertension. Hypertension, 58(5), 811–817. https://doi.org/10.1161/HYPERTENSIONAHA.111.179788

9. Pickering, T. G., Shimbo, D., & Haas, D. (2006). Ambulatory blood-pressure monitoring. New England Journal of Medicine, 354(22), 2368–2374. https://doi.org/10.1056/NEJMra060433

10. Thayer, J. F., Yamamoto, S. S., & Brosschot, J. F. (2010). The relationship of autonomic imbalance, heart rate variability, and cardiovascular disease risk factors. International Journal of Cardiology, 141(2), 122–131. https://doi.org/10.1016/j.ijcard.2009.09.543

Current Solutions for Post-COVID Fatigue

Navigating the Most Debilitating Sequela of Long COVID

By: Lennard M. Goetze, Ed.D

Post-COVID fatigue has emerged as one of the most persistent and life-altering sequelae of SARS-CoV-2 infection. Affecting millions worldwide, this form of exhaustion is not comparable to everyday tiredness. Patients frequently describe it as a “chronic low-battery state”—a condition in which even minimal physical or cognitive effort triggers profound, lingering exhaustion that does not resolve with rest. Often accompanied by brain fog, muscle weakness, dizziness, and autonomic symptoms, post-COVID fatigue represents a complex, multisystem disorder rather than a single symptom.

As research evolves, management strategies have shifted away from simplistic “push through it” approaches toward more nuanced, patient-centered solutions grounded in energy conservation, autonomic stabilization, and targeted symptom management.

Understanding the Nature of Post-COVID Fatigue

Unlike normal fatigue, post-COVID fatigue is unrelenting and non-restorative. Sleep may be prolonged yet ineffective, leaving patients waking unrefreshed. A defining feature for many is post-exertional malaise (PEM)—a delayed worsening of symptoms following physical, cognitive, or emotional exertion. PEM can occur hours or even days after activity and may last for days to weeks.

Common associated symptoms include:

Muscle weakness and heaviness
Joint and body pain
Lightheadedness or dizziness, especially when standing
Heart palpitations or exercise intolerance
Cognitive impairment (“brain fog”), including memory lapses and difficulty concentrating

This symptom constellation closely overlaps with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), and a significant subset of long COVID patients meet diagnostic criteria for ME/CFS months after infection.

Current Clinical Approach: Management over Cure

At present, there is no single curative therapy for post-COVID fatigue. Leading health authorities, including the CDC, emphasize that management must be individualized, adaptive, and symptom-focused. The primary goal is not rapid recovery, but functional stabilization and gradual improvement without triggering setbacks.

1. Energy Management and Pacing (Cornerstone Strategy)

Energy management—often referred to as pacing—is the most widely recommended and evidence-aligned approach. Pacing teaches patients to operate within their “energy envelope,” avoiding the boom-and-bust cycle that worsens fatigue.

Key pacing principles include:

Breaking activities into smaller, manageable steps
Alternating activity with rest before symptoms escalate
Prioritizing essential tasks and deferring non-critical ones
Tracking symptom responses to activity using logs or wearable data

Importantly, pacing is not deconditioning. It is a protective strategy that allows physiological systems time to recover while preventing exacerbation of PEM.

2. Rethinking Exercise: From Graded Therapy to Gentle Conditioning

Traditional graded exercise therapy (GET) is no longer broadly recommended for post-COVID fatigue, particularly in patients with PEM. Instead, clinicians now favor symptom-limited, adaptive movement.

Appropriate approaches may include:

Gentle stretching or range-of-motion exercises
Recumbent or seated movements for those with orthostatic intolerance
Breathing-based movement (e.g., diaphragmatic breathing, restorative yoga)

Progression—if tolerated—should be slow, flexible, and reversible. Any increase in symptoms signals the need to scale back.

3. Addressing Autonomic Dysfunction (POTS-like Features)

Many post-COVID fatigue patients exhibit signs of autonomic nervous system dysregulation, including postural orthostatic tachycardia syndrome (POTS). Management strategies may include:

Increased fluid and electrolyte intake (when medically appropriate)
Compression garments to improve venous return
Slow positional changes (lying → sitting → standing)
Medications such as beta-blockers or fludrocortisone in select cases

Stabilizing autonomic function often leads to measurable improvements in fatigue tolerance and cognitive clarity.

4. Cognitive Rehabilitation for Brain Fog

Cognitive symptoms are among the most distressing aspects of post-COVID fatigue. Clinics specializing in neuro-rehabilitation, such as those cited by Cognitive FX, emphasize targeted cognitive pacing rather than overexertion.

Effective strategies include:

Short, focused cognitive tasks with scheduled breaks
Limiting multitasking and sensory overload
Speech-language or occupational therapy for executive dysfunction
Digital detox periods to reduce neurological fatigue

Patients often benefit from reframing brain fog as a neuro-energy issue, not a personal failure or lack of effort.

5. Sleep Optimization (Without Over-Sedation)

While sleep is rarely restorative in post-COVID fatigue, optimizing sleep quality remains essential. Interventions may include:

Consistent sleep-wake schedules
Light exposure management (morning light, evening reduction)
Addressing sleep apnea, restless legs, or circadian disruption
Judicious use of sleep aids, avoiding heavy sedatives when possible

The goal is sleep regulation, not forced sedation.

6. Nutritional and Metabolic Support

Though no single diet cures post-COVID fatigue, nutritional optimization can reduce symptom burden. Areas of focus include:

Adequate protein intake to support muscle and mitochondrial function
Correction of deficiencies (iron, B12, vitamin D, magnesium)
Stabilizing blood glucose to reduce energy crashes
Anti-inflammatory dietary patterns when tolerated

Some clinicians explore mitochondrial-supportive supplements, though evidence remains emerging and individualized oversight is essential.

7. Mental Health Support Without Psychologizing the Condition

Depression and anxiety commonly coexist with post-COVID fatigue—but they are not the cause. Psychological support plays a role in coping, adjustment, and stress regulation rather than symptom dismissal.

Helpful modalities include:

Trauma-informed counseling
Mindfulness-based stress reduction
Acceptance-based therapies focused on living within limitations

Validating the biological reality of post-COVID fatigue is critical to effective care.

Long-Term Outlook and Ongoing Research

Post-COVID fatigue can persist for months or years. Recovery trajectories vary widely, with some patients improving gradually and others experiencing prolonged disability. Ongoing research is exploring immune dysregulation, viral persistence, endothelial dysfunction, and impaired oxygen utilization as contributing mechanisms.

For now, the most effective solutions emphasize listening to the body, respecting physiological limits, and avoiding harm from overexertion.

Conclusion

Post-COVID fatigue is a complex, disabling condition that demands a departure from conventional fatigue management. While there is no single cure, current solutions—centered on pacing, autonomic stabilization, cognitive rehabilitation, and individualized support—offer a pathway toward functional improvement and dignity in care.

For patients, clinicians, and advocacy organizations alike, the message is clear: post-COVID fatigue is real, measurable, and deserving of informed, compassionate management—not dismissal or minimization.