What are the next steps for a patient experiencing nausea, dizziness, and migraines while taking Adderall (amphetamine and dextroamphetamine) for Attention Deficit Hyperactivity Disorder (ADHD)?

Managing Nausea, Dizziness, and Migraine on Adderall

These symptoms are common, dose-related side effects of Adderall that require immediate dose adjustment or timing modification, and if migraines persist despite these changes, the patient needs concurrent migraine-specific treatment with triptans plus NSAIDs while strictly limiting Adderall use to prevent medication-overuse headache. 1, 2

Immediate Assessment and Dose Modification

First Step: Adjust Adderall Dosing Strategy

• Reduce the current Adderall dose immediately, as nausea, dizziness, and headache are among the seven side effects that occur more frequently with stimulants than placebo and typically respond to dose reduction 1
• Change the timing of administration—give the dose with food to reduce nausea, and avoid late evening doses which can worsen insomnia and contribute to next-day symptoms 1, 3
• If the patient is on immediate-release formulation, consider switching to extended-release (Adderall XR) which may reduce peak-related side effects like nausea and dizziness 1

Monitor for Medication-Overuse Headache

• Critically important: If the patient is taking any acute headache medications (NSAIDs, triptans, or analgesics) more than 2 days per week, they have developed medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 2, 4
• Stimulants themselves can trigger or worsen migraines in susceptible individuals, creating a vicious cycle 1

Migraine-Specific Treatment Protocol

Acute Migraine Treatment (Limited to ≤2 Days Per Week)

• First-line combination therapy: Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg taken at migraine onset while pain is still mild—this combination is superior to either agent alone 2
• For moderate-to-severe attacks with nausea: Use sumatriptan nasal spray 5-20 mg to bypass gastric absorption issues 5, 4
• Add metoclopramide 10 mg for nausea, which provides dual benefit by treating nausea AND providing direct analgesic effects through central dopamine receptor antagonism 2, 5

Critical Frequency Limitation

• Strictly limit all acute migraine medications to no more than 2 days per week (10 days per month) to prevent medication-overuse headache 2, 4
• If the patient needs acute treatment more than twice weekly, initiate preventive therapy immediately 2

Preventive Migraine Therapy (If Headaches Occur >2 Times Per Week)

First-Line Preventive Options

• Propranolol 80-240 mg/day has the strongest evidence for migraine prevention and may also help with stimulant-induced tachycardia 1
• Amitriptyline 30-150 mg/day is particularly useful if the patient has mixed migraine and tension-type headache, though it may cause drowsiness and weight gain 1
• Topiramate or divalproex sodium are alternatives, though they carry risks of weight gain, hair loss, and teratogenic potential 1

Important Contraindication

• Do not use beta-blockers with intrinsic sympathomimetic activity (acebutolol, alprenolol, oxprenolol, pindolol) as they are ineffective for migraine prevention 1

Managing Nausea Specifically

Standalone Nausea Treatment

• Metoclopramide 10 mg orally 20-30 minutes before Adderall can prevent nausea and provides synergistic benefit 2, 5
• Avoid using metoclopramide more than 2 days per week to prevent medication-overuse headache 5
• Contraindications for metoclopramide: pheochromocytoma, seizure disorder, GI bleeding, or GI obstruction 5

Alternative Antiemetic

• Prochlorperazine 25 mg is an alternative if metoclopramide is contraindicated, though it carries additional risks of tardive dyskinesia, hypotension, and arrhythmias 5

When to Consider Stopping or Switching Adderall

Red Flags Requiring Medication Change

• If dose reduction and timing adjustments fail to resolve symptoms after 2-3 weeks, consider switching to a non-stimulant ADHD medication like atomoxetine 1
• If migraines become severe, frequent (>2 times per week), or intractable despite preventive therapy, the stimulant may be the primary trigger and should be discontinued 1
• Severe or persistent dizziness may indicate cardiovascular effects requiring immediate evaluation and likely medication discontinuation 1

Critical Pitfalls to Avoid

• Never allow the patient to increase frequency of acute headache medication use in response to worsening symptoms—this creates medication-overuse headache 2, 4
• Do not prescribe opioids or butalbital-containing compounds for these headaches, as they lead to dependency, rebound headaches, and loss of efficacy 2
• Do not continue Adderall at the same dose hoping symptoms will resolve—they are dose-related and require intervention 1
• Do not use oral medications if the patient is actively vomiting—switch to non-oral routes (nasal spray triptans or subcutaneous sumatriptan 6 mg) 4

Follow-Up Timeline

• Reassess symptoms within 1-2 weeks after dose adjustment 1
• If migraines persist at reduced Adderall dose, initiate preventive therapy and reassess after 2-3 months for oral preventives 2
• Monitor for medication-overuse headache by tracking acute medication use frequency 2, 4