Which one causes oculogyric crises, Dramamine (Dimenhydrinate), Maxolon (Metoclopramide), or Motilium (Domperidone)?

Metoclopramide (Maxolon) Causes Oculogyric Crisis, Not Dramamine or Motilium

Among Dramamine (dimenhydrinate), Maxolon (metoclopramide), and Motilium (domperidone), metoclopramide is the medication most strongly associated with causing oculogyric crisis due to its dopamine receptor blocking properties. 1, 2

Mechanism and Risk Assessment

Metoclopramide (Maxolon)

• Directly blocks dopamine D2 receptors in the central nervous system
• FDA drug label explicitly lists oculogyric crisis as an adverse reaction 1
• Acute dystonic reactions including oculogyric crisis occur in approximately:
  • 0.2% of patients receiving standard doses (30-40 mg/day)
  • 2% in cancer patients over 30-35 years receiving higher doses
  • 25% or higher in pediatric patients and adults under 30 years 1
• Symptoms include involuntary upward eye deviation, facial grimacing, torticollis, and rhythmic tongue protrusion 1, 3

Domperidone (Motilium)

• While also a D2 dopamine receptor antagonist, it has limited central nervous system penetration
• Less likely to cause extrapyramidal symptoms compared to metoclopramide 2
• Associated primarily with QTc prolongation rather than extrapyramidal effects 2
• Not typically associated with oculogyric crisis in clinical practice

Dimenhydrinate (Dramamine)

• Antihistamine with anticholinergic properties
• Actually used to treat oculogyric crisis rather than cause it 4
• Adverse effects include hypotension, dizziness, blurred vision, and dry mouth 2
• Not associated with causing oculogyric crisis

Clinical Presentation of Oculogyric Crisis

• Characterized by sustained, conjugate upward deviation of the eyes 3, 5
• Patient's awareness remains intact during episodes 3
• May be accompanied by:
  • Blepharospasm
  • Neck flexion
  • Jaw opening with/without tongue protrusion
  • Autonomic symptoms 5
• Episodes can last from seconds to hours 6
• Can be confused with seizures or other neurological conditions if patient history is incomplete 6

Risk Factors for Metoclopramide-Induced Oculogyric Crisis

• Younger age (especially under 30 years)
• Higher doses (particularly with chemotherapy regimens)
• Lack of prophylactic anticholinergic medication
• Parenteral administration
• Prior history of dystonic reactions 5

Management of Oculogyric Crisis

1. Immediate administration of parenteral anticholinergic medication:

   • Intramuscular benztropine 1-2 mg OR
   • Intravenous/intramuscular diphenhydramine 25-50 mg 4, 7

2. Continue oral anticholinergic therapy for 2-3 days to prevent recurrence:

   • Oral diphenhydramine 25-50 mg TID OR
   • Benztropine 1-2 mg BID 4

3. Address the causative agent:

   • Discontinue metoclopramide if possible
   • Consider alternative antiemetic with lower risk of extrapyramidal symptoms
   • If metoclopramide must be continued, reduce dose and provide prophylactic anticholinergic medication 4

Clinical Implications

When selecting an antiemetic or prokinetic agent, metoclopramide should be used with caution, especially in high-risk populations such as young adults and children. For patients requiring prokinetic therapy with lower risk of extrapyramidal effects, domperidone may be preferred where available, though it carries its own cardiac risks 2. Dimenhydrinate, while effective for motion sickness and vertigo, lacks the prokinetic effects of the other medications but also lacks the risk of oculogyric crisis.