Abstract: PUB220
Unilateral Occipital Headache with Ipsilateral Jaw Pain Mimicking an Atypical Adverse Effect of Lisinopril
Session Information
Category: Pharmacology (PharmacoKinetics, -Dynamics, -Genomics)
- 1900 Pharmacology (PharmacoKinetics, -Dynamics, -Genomics)
Authors
- Coburn, Brandon, WVU Medicine, Morgantown, West Virginia, United States
- Murari, Ujjwala, WVU Medicine, Morgantown, West Virginia, United States
- Kaushal, Amit, WVU Medicine, Morgantown, West Virginia, United States
- Schmidt, Rebecca J., WVU Medicine, Morgantown, West Virginia, United States
Introduction
ACE inhibitor (ACEi) headache is well known and usually bilateral. A reproducible one-sided headache with ipsilateral jaw pain, timed to dosing, is less commonly described. We report a young man on lisinopril for proteinuria who developed this pattern, with resolution after switching to an ARB.
Case Description
A 30-year-old male was referred for evaluation of microscopic hematuria and proteinuria found on routine urinalysis. He reported 8–9 years of intermittent findings and frothy urine without gross hematuria. Workup showed normal renal function, negative SPEP/UPEP, normal LC ratio, and no hematuria on repeat urinalysis. Initial UPCR was 453 mg/g, rising to 1.6 g/g. Lisinopril 10 mg daily was initiated, resulting in improvement of UPCR to 0.2 g/g at 6 months and <7 mg/g by September 2025. In April 2026, he reported recurrent right occipital headache with ipsilateral jaw pain occurring within six hours of dosing. There was no temporal artery tenderness, dental pathology, lip/tongue swelling, or respiratory distress. Prior ED evaluation with head CT was unremarkable. Since symptom onset correlated with lisinopril Tmax (6–8 hours), lisinopril was discontinued due to suspected adverse effect, and losartan 25 mg daily was started with resolution of symptoms.
Discussion
ACEi headache is typically bilateral and dose-related; right-sided occipital pain with ipsilateral jaw involvement is atypical. ACE inhibitors increase bradykinin levels which may contribute to uncommon pain syndromes via vasodilatory or neurovascular mechanisms particularly in susceptible pts. Chronic exposure to elevated bradykinins can sensitize trigeminal nerve endings, occipital nerve roots (C2-C3), and TMJ sensory fibers. Trigeminal autonomic cephalalgia, cervicogenic headache, and TMJ pain were considered but were less likely given symptom onset after drug administration and resolution after switching to an ARB, supporting a medication-related cause. The Naranjo adverse drug reaction probability scale score was 7, indicating a probable causal relationship between lisinopril and symptoms. Misidentification of drug-induced focal pain can lead to a prescribing cascade where patients are started on gabapentin, adding pill burden and side effects. A new headache pattern in a patient on long-term ACEi warrants a drug holiday before extensive neurology workup, especially when symptoms track with dose timing.