# A 65-year-old woman with treatment-resistant major depression has been on phenelzine 60 mg PO daily for 6 weeks. About 30 minutes after a dinner that included aged cheddar, salami, and red wine, she calls the clinic with a sudden severe pounding headache, neck stiffness, palpitations, and nausea. The clinic obtains BP 230/130 mmHg, HR 110. Which action should the nurse prioritize?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375260&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A 65-year-old woman with treatment-resistant major depression has been on phenelzine 60 mg PO daily for 6 weeks. About 30 minutes after a dinner that included aged cheddar, salami, and red wine, she calls the clinic with a sudden severe pounding headache, neck stiffness, palpitations, and nausea. The clinic obtains BP 230/130 mmHg, HR 110. Which action should the nurse prioritize?

## Option

1. Instruct the patient to take a prescribed as-needed antihypertensive if available, lie down in a dark, quiet room, apply a cool compress, and contact the clinic if symptoms persist for more than 2 hours.
2. Advise the patient to take acetaminophen 1000 mg for the headache, monitor blood pressure at home every 2 hours, and schedule a follow-up appointment with her psychiatrist within 24 to 48 hours.
3. Instruct the patient to discontinue phenelzine immediately, take an as-needed benzodiazepine for anxiety, and come to the clinic for a blood pressure check in the morning, while continuing to monitor at home.
4. Activate emergency services for a hypertensive crisis, support the patient until IV antihypertensive (phentolamine or nicardipine) can be given, and review tyramine-containing foods. **✔ Correct answer**

**Correct answer: 4**

## Explanation

MAOIs (phenelzine, tranylcypromine, isocarboxazid, selegiline at antidepressant doses) inhibit gut and hepatic monoamine oxidase, so dietary tyramine from aged cheese, cured meats, fermented soy, draft/red wine, and tap beer is not metabolized and triggers a massive norepinephrine release — a hypertensive crisis with sudden occipital pounding headache, neck stiffness, palpitations, sweating, and BP often >200/120. This is an emergency: activate EMS, place the patient supine with head elevated, prepare for IV alpha-blockade (phentolamine 5–10 mg IV) or careful nicardipine, and avoid abrupt overshoot lowering. Recommending a walk dismisses an emergency. Increasing phenelzine adds risk. Self-stopping does not address the active crisis and can cause MAOI rebound issues; tapering is required when discontinuing.

## In-depth explanation

On MAOIs, the dietary "AGE" rule helps — Aged, Cured/Fermented, Etc. (draft beer, soy sauce, fava beans, smoked fish). Patients also carry a wallet card and avoid sympathomimetic OTC decongestants and SSRIs/SNRIs.

## Clinical scenario

Scenario 65-year-old woman, treatment-resistant MDD, on phenelzine 60 mg PO daily for 6 weeks. After dinner with aged cheddar, salami, and 2 glasses of red wine, she develops a sudden pounding occipital headache, neck stiffness, palpitations, and nausea within 30 minutes. Clinic BP 230/130 mmHg, HR 110, alert. No focal neuro deficits at this moment. Allergies: none. No SSRI/SNRI/triptan/meperidine in her chart.

## Key concepts

- **MAOI** — Monoamine Oxidase Inhibitor — phenelzine, tranylcypromine, isocarboxazid (oral, irreversible) and transdermal selegiline. Used in treatment-resistant or atypical depression. Need 14-day washout before/after most other antidepressants and 5 weeks after fluoxetine.
- **Tyramine reaction** — Hypertensive crisis triggered by tyramine-containing foods on a MAOI. Avoid: aged cheese (cheddar/blue/parmesan), cured/smoked meats, fermented soy products and miso/soy sauce, draft and unpasteurized beer, red wine, fava beans, sauerkraut, overripe avocado, smoked/pickled fish.
- **Hypertensive crisis management** — Sudden severe BP elevation with target organ symptoms; lower BP gradually (no more than ~25% in the first hour) using IV phentolamine (alpha-blockade for MAOI/pheo cases), nicardipine, or labetalol. Avoid sublingual nifedipine due to overshoot risk.

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