What medication is recommended for a 30-year-old female with a history of migraine and Generalized Anxiety Disorder (GAD) for short-term flight anxiety, currently taking cholecalciferol (Vitamin D-3), cyclobenzaprine (Flexeril), escitalopram (Lexapro), magnesium gluconate (Mag-G), norethindrone (Jencycla), riboflavin (Vitamin B2), rimegepant (Nurtec), and ubrogepant (Ubrelyvy)?

From the Guidelines

For a 30-year-old female with migraine and generalized anxiety disorder seeking short-term flight anxiety medication, I recommend a short-acting benzodiazepine such as lorazepam (Ativan) 0.5-1 mg taken 30-60 minutes before the flight, as it is a commonly prescribed medication for short-term anxiety relief with a favorable side-effect profile 1. When considering her current medications, including escitalopram (LEXAPRO) 10 mg tablet, it is essential to note that combining SSRIs with benzodiazepines is generally safe, but monitoring for increased sedation or other adverse effects is crucial.

• Her current medications, such as rimegepant (NURTEC) 75 mg dispersible tablet and ubrogepant (UBRELVY) 100 mg tablet for migraine, do not have significant interactions with benzodiazepines that would contraindicate their use.
• Supplements like cholecalciferol (VITAMIN D-3), magnesium gluconate (MAG-G), and riboflavin (VITAMIN B2) are also unlikely to interact with benzodiazepines in a clinically significant way. However, it is crucial to advise her to avoid alcohol consumption during the flight, as it can potentiate the sedative effects of benzodiazepines.
• For longer flights, an additional dose of lorazepam may be taken after 6-8 hours if needed, but caution should be exercised regarding driving after arrival due to potential residual sedation. Given the short-term use for flight anxiety, the risk of dependence on benzodiazepines is minimal, making lorazepam a reasonable choice for this patient's specific situation, as supported by guidelines suggesting the use of physician-prescribed anxiolytics with consideration of side-effect profiles and patient preference 1.

From the FDA Drug Label

WARNINGS Dependence and Withdrawal Reactions, Including Seizures Certain adverse clinical events, some life-threatening, are a direct consequence of physical dependence to alprazolam tablets. Even after relatively short-term use at the doses recommended for the treatment of transient anxiety and anxiety disorder (i.e., 0.75 to 4. 0 mg per day), there is some risk of dependence.

For short-term flight anxiety, alprazolam may be considered, but the risk of dependence and withdrawal reactions should be carefully weighed.

• The patient's history of migraine and GAD does not directly contraindicate the use of alprazolam.
• Current medications, including escitalopram, do not have a direct interaction with alprazolam that would prevent its use.
• However, the patient should be closely monitored for signs of dependence and withdrawal, especially if the treatment duration exceeds the recommended short-term use.
• The dose should be limited to the minimum effective dose, not exceeding 4 mg/day, to minimize the risk of dependence 2.

From the Research

Medication Options for Short-Term Flight Anxiety

The patient is seeking medication for short-term flight anxiety and is currently taking several medications, including escitalopram (LEXAPRO) 10 mg tablet for generalized anxiety disorder (GAD). Considering the patient's medication history and the need for short-term relief, the following options can be explored:

• Benzodiazepines: According to 3, benzodiazepines can be effective for acute stress reactions and episodic anxiety. However, their use should be limited to short courses (ideally 4 weeks maximum) to minimize the risk of tolerance, dependence, and withdrawal effects.
• Hydroxyzine: As mentioned in 4, hydroxyzine has been used to treat anxiety and is equivalent in efficacy to benzodiazepines. However, its use is not recommended as a first-line treatment due to the high risk of bias in the included studies.
• Escitalopram: The patient is already taking escitalopram, which is effective in treating GAD, as stated in 5 and 6. However, its efficacy in treating short-term flight anxiety is not explicitly mentioned.

Considerations for Flight Anxiety Treatment

When considering treatment for flight anxiety, the following factors should be taken into account:

• Alprazolam: As mentioned in 7, alprazolam can reduce self-reported anxiety in the short term but may hinder the therapeutic effects of exposure in the long term.
• Short-term vs. long-term treatment: The patient is seeking short-term relief, which may require a different treatment approach than long-term management of GAD.
• Potential interactions: The patient's current medications, including escitalopram, should be considered when selecting a treatment for short-term flight anxiety to minimize potential interactions.

Potential Treatment Approaches

Based on the available evidence, potential treatment approaches for short-term flight anxiety in this patient could include:

• Benzodiazepines: A short course of benzodiazepines, such as diazepam, may be effective in reducing anxiety during the flight, as mentioned in 3.
• Hydroxyzine: Hydroxyzine may be considered as an alternative to benzodiazepines, although its efficacy and safety profile should be carefully evaluated, as stated in 4.
• Escitalopram: The patient's current escitalopram regimen may be continued, and its efficacy in managing GAD symptoms may also help alleviate flight anxiety, as mentioned in 5 and 6.