I have a love-hate relationship with Zofran (Ondansetron). Though Zofran is FDA-approved only for use in treating N/V related to chemotherapy, radiation & surgery, with it’s low risk profile, Zofran has become a reflex choice for any nausea/emesis symptoms. Given out like candy, it’s benign halo often makes it slip under the radar.
Headache is a common & underrecognized side-effect of Zofran. In the hospital setting headaches are common – they can delays discharges, make patients reluctant to eat or walk, make them irritable and can result in more tests to figure out a cause. Although a search on Pubmed shows incidence of Zofran-Induced headaches upto 30% in some studies, I often see Zofran missed on the suspected list of offenders. [ Other common side effects of Zofran include constipation, dizziness, restlessness. QT prolongation & Serotonin syndrome are thankfully rare.]
The mechanism of Zofran-induced headache is unknown and tough to predict (it’s known however that higher doses increase risk). So in the following scenarios when headaches are an independent risk, I use Zofran as second or third choice for N/V control :
- LP or post-Spinal Anesthesia for surgery
- Migraine history (zofran known to precipitate migraines)
- NPO status (“hunger headaches” due to dehydration, low glucose, caffeine withdrawal – I get a raging headache without my caffeine !)
- Ongoing headache
- Previous headache history with Zofran
(LMNOP to remember the above)
Learning Points:
- Stick with low dose Zofran (4mg)
- Switch to an alterative antiemetic if patient reports any headache
- While Compazine comes with its own side-effect profile, in my experience, an alternating q6hrs use of low-dose Zofran with low-dose Compazine often achieves good nausea control while reducing side-effects of both drugs
- Try using another agent first if patients have an expected risk of headache regardless as outlined in LMNOP above
