Many medications are available to treat high blood pressure (hypertension). Though some were once commonly prescribed, they are not recommended as first-line treatments for many people for various reasons.

There is no single “best” or “worst” blood pressure medication—each person’s needs and medical history are unique. Healthcare providers consider several factors, including your medical history, cost and insurance coverage, and the potential for side effects or drug interactions. That said, some medications are less effective or come with more safety concerns than others.

1. Alpha-Blockers

Alpha-blockers are a class of drugs taken to lower high blood pressure. Alpha-blockers are sometimes taken to control symptoms of benign prostatic hyperplasia (BPH), a condition that causes enlargement of the prostate gland. They work by relaxing muscles in the blood vessel walls, allowing them to widen, which helps lower blood pressure.

Some examples of alpha-blockers taken for high blood pressure include:

• Cardura (doxazosin)
• Minipress (prazosin)
• Terazosin

Studies have found that alpha-blockers only have a “modest” effect on lowering blood pressure—an average of 8 millimeters of mercury (mmHg) for systolic blood pressure (the top number of the reading) and 5 mmHg for diastolic blood pressure (the bottom number of the reading).

Alpha-blockers are not recommended as the first-choice treatment for high blood pressure in clinical guidelines. However, an alpha-blocker may be appropriate in some cases—for example, in a male with both high blood pressure and BPH.

Some of the concerning side effects of alpha-blockers include:

2. Alpha-2 Agonists

Alpha-2 agonists are a class of drugs taken to lower blood pressure but are not typically a first choice of treatment, according to guidelines. They work by blocking brain signals that increase the heart rate and narrow blood vessels, which helps lower blood pressure.

Alpha-2 agonists include:

• Catapres (clonidine)
• Guanfacine
• Methyldopa

These medications are often avoided due to safety concerns. Side effects of alpha-2 agonists include:

• Drowsiness
• Dizziness
• Fatigue
• Headache
• Depression

Suddenly stopping clonidine may cause a rapid and serious increase in blood pressure, as well as other withdrawal symptoms such as nervousness, agitation, headache, and shaking.

Clonidine can also make certain heart problems worse, especially in people with heart rhythm problems, like a slow heart rate or heart block.

3. Beta-Blockers

Beta-blockers are not recommended as a first choice of treatment for high blood pressure, according to guidelines.

Beta-blockers work by decreasing the rate and force of the heart pumping blood, which helps lower blood pressure. Some examples of beta blockers include:

• Tenormin (atenolol)
• Lopressor (metoprolol tartrate)
• Toprol XL (metoprolol succinate extended-release)

However, some beta-blockers can worsen symptoms of asthma or other lung conditions, as well as peripheral vascular disease (a condition that causes narrowing, blockage, or spasms in the blood vessel). Beta-blockers can mask symptoms of hypoglycemia (low blood sugar) in people with diabetes who use insulin.

They can also cause side effects such as:

• Fatigue
• Insomnia
• Unusual dreams
• Decreased ability to exercise
• Slow heart rate
• Rash
• Cold hands and feet

In some instances, beta-blockers are an appropriate choice for treatment on their own or with other medicines, such as in people with high blood pressure who:

• Have a resting heart rate greater than 80 beats per minute. This is because beta-blockers can slow the heart rate.
• Have angina (chest pain) or who have had a recent heart attack because beta-blockers may improve survival after a heart attack.

4. Vasodilators

Vasodilators are taken to lower blood pressure but are not a first-choice medication. They work by relaxing the muscles in the walls of the blood vessels, allowing the blood vessels to widen and helping blood flow through.

Vasodilators include:

These medications are often avoided for the treatment of high blood pressure due to their risk of serious side effects. Some of the side effects of vasodilators include:

• Headache
• Constipation
• Chest pain
• Lower leg swelling/fluid retention
• Fast heart rate
• Joint pain

Vasodilators can sometimes increase chest pain and, in some cases, cause heart problems, including heart attack, especially in people with preexisting heart conditions.

5. Loop Diuretics

There are several types of diuretics (water pills). Loop diuretics, specifically, are the most potent (strongest) type of diuretic.

Diuretics work in the kidneys. Loop diuretics work in a part of the kidneys called the loop of Henle, hence their name. Diuretics help control fluid retention (edema) and blood pressure by helping the body eliminate water and sodium (salt) in the urine (also making you pee frequently).

Loop diuretics include:

• Lasix (furosemide)
• Bumex (bumetanide)
• Torsemide

Because of their powerful diuretic effect, loop diuretics can cause concerning side effects, such as:

• Electrolyte imbalances (e.g., low sodium, potassium, or magnesium). Electrolyte imbalances are more likely to occur in certain people, such as older adults and people with kidney problems, and can cause complications like heart rhythm irregularities.
• Allergic reactions.
• Damage to the inner ear, such as tinnitus (ringing in the ears) or hearing loss.

Alternatively, thiazide diuretics are another type of diuretic that is a first-choice treatment for high blood pressure.

What Is the First Blood Pressure Drug of Choice?

First-choice blood pressure medications, according to the American College of Cardiology/American Heart Association Guidelines, include:

Depending on the severity of your high blood pressure, healthcare providers may start with one or more medications, with selection depending on individual factors. For example, ACE inhibitors and ARBs should never be taken during pregnancy because they can harm the fetus, so those who are pregnant or planning to become pregnant would not be prescribed one of these drugs.

Your healthcare provider may recommend lifestyle modifications along with prescription drugs. For example, some possible lifestyle changes include:

• Weight loss, if necessary
• Following a heart-healthy diet with reduced salt intake, such as the DASH diet
• Increased exercise (approved by a healthcare provider)
• Avoiding or limiting alcohol to two drinks per day or less for males or one drink per day or less for females

Medications That Worsen Blood Pressure

Some substances and medications—both over-the-counter (OTC) and prescription—are associated with increased blood pressure, such as:

• Alcohol
• Amphetamines, such as Adderall (mixed amphetamine salts)
• Illicit substances such as ecstasy and cocaine
• Certain antidepressants, such as Wellbutrin (bupropion) and Effexor XR (venlafaxine)
• Caffeine
• Corticosteroids (steroid hormones used to treat certain inflammatory conditions)
• Certain weight-loss medicines, such as Adipex (phentermine)
• Estrogens, including birth control pills
• Immunosuppressants (drugs that block parts of the immune system), such as cyclosporine
• OTC cold and cough medicines that contain an oral decongestant like pseudoephedrine (e.g., Sudafed)
• Certain migraine medications, such as triptans
• Nicotine
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Testosterone

This is not a full list of substances and medicines that can increase your blood pressure. Consult your healthcare provider for more information and medical advice.

Summary

Some blood pressure medications are no longer recommended as first-line treatments due to limited effectiveness or side effects. For example, alpha-blockers, alpha-2 agonists, and vasodilators are not typically preferred as a first choice for lowering blood pressure because they may have modest effects or cause side effects like dizziness, fatigue, or heart problems.

Guidelines recommend thiazide diuretics, calcium channel blockers, ACE inhibitors, or ARBs as first-line treatments. Healthcare providers will choose the best option based on individual considerations. Lifestyle changes, such as diet, exercise, and weight loss (if necessary), can also help manage high blood pressure.