Ondansetron-induced migraine-type headache

We again highlight this clinically relevant though under-stated side effect of ondansetron. We present a case ofsevere migraine that was precipitated in a young femalefollowing the administration of ondansetron for the pro-phylaxis of postoperative nausea and vomiting (PONV).Consent to publish details about this case was obtainedfrom the patient.A 26-yr-old female was admitted for de´bridement of aninfected wound following a cat scratch to her hand.Her medical history included depression, mild asthma,and occasional migraines. Physical examination andinvestigations were unremarkable except for an elevatedC-reactive protein. Anesthesia was induced intravenouslywith fentanyl and propofol, a laryngeal mask airway device(LMAD) was inserted, and anesthesia was maintained withsevoflurane in an air-oxygen mixture. Spontaneousbreathing was maintained throughout the procedure, whichlasted approximately 45 min. Five minutes before the endof the procedure, dexamethasone 8 mg and ondansetron4 mg were administered for the prophylaxis of PONV. Thepatient’s vital signs remained stable and the LMAD wasremoved uneventfully after about ten minutes administa-tion of ondansetron . However, approximately ten minuteslater, the patient began complaining of a severe throbbingheadache that was reported as frontal in location andassociated with mild photophobia and nausea. The patientdescribed the headache as similar to her previous migraineattacks. The symptoms lasted for about 30 min andresponded to treatment with oral codeine and intravenousfluids. Three days later, the patient received the sameanesthetic for a repeat de´bridement, including ondansetron4 mg. The same type of headache recurred after anesthesia;the symptoms lasted for about 20 min and again respondedto oral codeine.Owing to the ongoing infection of her wound, thepatient underwent an additional three de´bridements withinthe next ten days. Ondansetron was omitted on all threeoccasions, as it was felt that this could have precipitatedher headaches in the initial two postoperative recoveryperiods. After each of these anesthetics, the patient wokewithout any headache and was soon discharged to the ward.On follow up visits, she expressed her satisfaction with theanesthetic regime that was used on the previous threeoccasions.Ondansetron is a 5-hydroxytyptamine (5-HT) type 3receptor antagonist drug commonly used for the prophy-laxis and treatment of PONV.