Can Dramamine (dimenhydrinate) cause oculogyric crisis?

Dramamine (Dimenhydrinate) and Oculogyric Crisis

Dramamine (dimenhydrinate) can cause oculogyric crisis despite being an antihistamine, as it contains diphenhydramine which has been documented to have paradoxical effects in some patients. 1

Mechanism and Risk

Oculogyric crisis is typically characterized by:

• Sustained dystonic, conjugate, and upward deviation of the eyes
• Intact awareness during episodes
• Possible accompanying symptoms including blepharospasm, neck flexion, and autonomic symptoms 2, 3

While oculogyric crisis is most commonly associated with:

• Dopamine receptor blocking agents (typical antipsychotics)
• Antiemetics like metoclopramide
• Certain antidepressants and antiepileptics 2

Diphenhydramine (a component of dimenhydrinate/Dramamine) has a complex pharmacological profile:

• It is primarily used to treat allergic symptoms and as a sedative
• It has anticholinergic properties that typically counteract extrapyramidal symptoms
• However, the Gastroenterology guidelines specifically list "extrapyramidal effects" among diphenhydramine's potential adverse effects 1

Clinical Implications

This presents a paradoxical situation:

• Diphenhydramine is commonly used to treat oculogyric crisis at doses of 25-50mg IV/IM 4
• Yet it can also potentially cause oculogyric crisis in some patients 1

Risk factors that may increase susceptibility:

• Younger age
• Male sex
• Higher doses
• Concomitant use with other central nervous system depressants 2

Management of Dramamine-Induced Oculogyric Crisis

If oculogyric crisis occurs after Dramamine use:

1. Immediate discontinuation of Dramamine
2. Administration of anticholinergic medication:
   • Benztropine 1-2mg IM/IV
   • Alternative: Diphenhydramine 25-50mg IV/IM (though paradoxical in this case) 4
3. Consider adding benzodiazepine if symptoms persist (e.g., lorazepam) 4
4. Continue oral anticholinergic therapy for 2-3 days to prevent recurrence 4, 3

Important Considerations

• Differential diagnosis: Rule out epilepsy, functional neurological movement disorders, ocular tics, and other causes 3
• Monitor for at least 1-2 hours after treatment to ensure complete resolution 4
• Avoid promethazine for treatment as it can paradoxically worsen symptoms due to its own potential to cause extrapyramidal effects 4

Clinical Pearls

• Oculogyric crisis typically resolves quickly (minutes to an hour) with appropriate treatment 4
• The underlying pathophysiology involves an imbalance between cholinergic and dopaminergic pathways 3
• Patients with a history of movement disorders may be at higher risk
• Documentation of the reaction is crucial to avoid future exposure to the causative agent

This unusual adverse effect highlights the complex pharmacology of antihistamines and the importance of recognizing rare but serious medication side effects even with commonly used over-the-counter medications.