Is it normal for Tramadol, Ketorolac, Pregabalin (Lyrica), Dexamethasone, or Paracetamol (Acetaminophen) to cause generalized pruritus, flushing, and dizziness when changing positions?

Medication Side Effects: Pruritus, Flushing, and Orthostatic Dizziness

Yes, tramadol is the most likely medication causing your symptoms of generalized pruritus, flushing, and dizziness when changing positions, as these are documented side effects in its FDA labeling. 1

Analysis of Each Medication

Tramadol

• Pruritus: Listed as a common side effect (8-11% incidence within 90 days) in FDA labeling 1
• Flushing: Can occur as part of vasodilation effects 1
• Orthostatic dizziness: Dizziness/vertigo is the most common adverse effect (26-33% incidence) 1, and orthostatic hypotension is specifically mentioned 1
• Case reports document toxic dermatitis with "highly pruriginous maculopapulous eruption" from tramadol 2

Pregabalin (Lyrica)

• Pruritus: Not commonly associated with generalized pruritus without rash 3
• Dizziness: Common side effect (listed as one of the main adverse effects) 3
• Flushing: Not typically reported
• While pregabalin is actually used to treat certain types of pruritus 4, 5, it doesn't typically cause it

Ketorolac

• Pruritus: Not commonly reported 3
• Dizziness: Can occur but less frequently than with tramadol 3
• Flushing: Not typically reported

Dexamethasone

• Pruritus: Epidural dexamethasone has been associated with generalized pruritus 3, but not commonly with oral/IV forms
• Dizziness: Not commonly reported 3
• Flushing: Not commonly reported

Paracetamol (Acetaminophen)

• Pruritus: Rarely causes pruritus without other allergic manifestations 6
• Dizziness: Not commonly reported
• Flushing: Not commonly reported

Mechanism of Action

The constellation of symptoms you're experiencing is most consistent with tramadol's side effect profile:

1. Pruritus: Opioid-induced pruritus is common and affects 2-10% of patients receiving oral opioids 3. Tramadol, as an atypical opioid, can trigger this response through:

   • Histamine release
   • Direct opioid receptor stimulation in the central nervous system
   • Serotonergic effects

2. Orthostatic dizziness: Tramadol can cause orthostatic hypotension 1, which manifests as dizziness when changing positions due to:

   • Vasodilation effects
   • Central nervous system effects
   • Potential interaction with other medications

3. Flushing: Related to vasodilation and histamine release 1

Management Options

If tramadol is determined to be the cause:

1. Consider alternative pain management:

   • NSAIDs like ketorolac (if no contraindications) 3
   • Acetaminophen (paracetamol) alone or in combination therapy 6
   • Pregabalin for neuropathic pain 3

2. If tramadol must be continued:

   • Slower dose titration (FDA labeling indicates fewer side effects with 10-day titration vs. 4-day titration) 1
   • Antihistamines may help with pruritus 3
   • Changing positions slowly to minimize orthostatic symptoms

3. For persistent pruritus:

   • Ondansetron may reduce the severity of opioid-induced pruritus 3
   • Mirtazapine has shown benefit for pruritus in some cases 3, 7
   • Gabapentin has shown effectiveness in preventing morphine-induced pruritus 3

Important Considerations

• These symptoms could indicate sensitivity to tramadol and should be monitored closely
• If symptoms worsen or if you develop rash, urticaria, or respiratory symptoms, discontinue tramadol immediately as these could indicate a more serious allergic reaction
• The combination of these symptoms is most consistent with tramadol's known side effect profile, though individual sensitivity to any medication can vary

If symptoms persist despite management strategies, consider complete discontinuation of tramadol and consultation with a pain specialist for alternative pain management approaches.