The major problem with nitrate therapy is headache. According to proposed mechanisms, nitric oxide is the common mediator in experimental vascular headaches. Nitroglycerin produces a throbbing or pulsating sensation in many patients and an overt headache in many others. Often, the headaches attenuate or disappear with time, but 15 to 20 percent of patients are not able to tolerate long-acting nitrates because of headache. Patients should be encouraged to use analgesics during the initial days or weeks of nitrate therapy and should be educated as to the nature of this problem and its probable resolution with time. y

Nitroglycerin therapy can cause dose-related increases in intracranial pressure, which, in rare cases, can result in clinically overt syndrome. Finally, the hypotensive effects of nitroglycerin can result in dizziness and lightheadedness or even syncope.

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