What is the best treatment for a 59-year-old male with headache and vomiting, currently on meclizine and Excedrin?

From the Guidelines

I strongly recommend discontinuing meclizine and starting Zofran (ondansetron) 4 mg three times daily as needed for 30 days to manage the patient's nausea and vomiting, as this approach is supported by the most recent and highest quality evidence available, including the study published in the Annals of Internal Medicine 1. The patient's current symptoms of headache and vomiting can be better managed with ondansetron, which is effective in treating nausea and vomiting by blocking serotonin receptors in the brain and gut.

• The study published in the Annals of Internal Medicine 1 suggests that treating nausea and vomiting with an antiemetic is appropriate, even if the patient is not vomiting, as nausea itself is a disabling symptom of migraine attacks.
• Additionally, I suggest prescribing ibuprofen instead of Excedrin for the patient's headache, as ibuprofen has anti-inflammatory properties and lacks the caffeine and acetaminophen found in Excedrin, which can cause rebound headaches with prolonged use.
• The patient's request for a memo to obtain his wrist brace back should also be addressed, as the wrist brace will provide support and stability to the patient's right wrist, potentially alleviating any discomfort or preventing further injury.
• It is also important to consider the patient's overall management plan, including the potential need for preventive therapy, as recommended by the study published in the Annals of Internal Medicine 1, which suggests that patients with frequent or severe migraine attacks should be evaluated for preventive therapy.

From the FDA Drug Label

The following adverse reactions associated with the use of meclizine hydrochloride were identified in clinical studies or postmarketing reports. Because some of these reactions were reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Anaphylactic reaction, drowsiness, dry mouth, headache, fatigue, and vomiting. Adverse Reactions: Advise patients that meclizine hydrochloride tablets may cause anaphylactic reaction, drowsiness, dry mouth, headache, fatigue, vomiting and, on rare occasions, blurred vision

The patient's symptoms of headache and vomiting are listed as potential adverse reactions to meclizine 2, which suggests that the medication may be contributing to these symptoms. It is reasonable to consider alternative treatments, such as Zofran, as planned.

From the Research

Patient's Current Medications and New Prescriptions

• The patient is currently taking meclizine for nausea and Excedrin for migraine.
• The patient will be discontinued from meclizine and started on Zofran (4 mg TIDPRN) for 30 days.
• The patient will also be prescribed ibuprofen and a memo for his right wrist brace.

Rationale for Discontinuing Meclizine

• Meclizine has been shown to be effective in preventing nausea and vomiting in certain populations, such as those undergoing surgery 3 or taking emergency contraceptive pills 4.
• However, in the context of the patient's current symptoms, the decision to discontinue meclizine and start Zofran may be due to the fact that Zofran is a more effective antiemetic for certain types of nausea and vomiting, such as chemotherapy-induced nausea and vomiting 5.

Rationale for Prescribing Zofran

• Zofran (ondansetron) is a serotonin antagonist that is highly effective in treating chemotherapy-induced nausea and vomiting 5.
• It has also been shown to be effective in reducing nausea severity in adult emergency department patients with undifferentiated nausea and vomiting 6.
• The prescription of Zofran for 30 days may be intended to provide ongoing antiemetic coverage for the patient's symptoms.

Considerations for Future Treatment

• The patient's response to Zofran and ibuprofen should be monitored, and adjustments to their medication regimen may be necessary if their symptoms persist or worsen.
• Other antiemetic options, such as metoclopramide or palonosetron, may be considered if the patient's symptoms do not respond to Zofran 6, 7.