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Transient elevation of liver enzyme levels occurs in a small number of patients treated with serotonin antagonists.In clinical trials, serotonin antagonists have caused self-limited, asymptomatic QT prolongation and QRS widening.13 Therefore, these agents should be used with caution in patients with underlying QT prolongation.Because of the efficacy of dopamine antagonists in treating migraine headaches, dopamine is thought to be a primary mediator.

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Three primary pathophysiologic pathways are involved in the stimulation of the physiologic vomiting center in the medulla that directly mediates nausea and vomiting.3 This center can be stimulated by vestibular fibers, afferent visceral fibers, and input from the chemoreceptor trigger zone in the base of the fourth ventricle4 receptor, and anticholinergic agents inhibit the action of acetylcholine at the muscarinic receptor.

Both drug classes limit stimulation of the vomiting center from the vestibular system (which is rich in histamine and acetylcholine) but have minimal effect on afferent visceral stimulation.5Antihistamines such as meclizine (Antivert) are associated with minor side effects involving the central nervous system, such as confusion, sedation, dizziness, tinnitus, insomnia, incoordination, fatigue, and tremors.56 Scopolamine (Transderm Scop) is a primary antimuscarinic agent with prominent central nervous system activity.

Evidence-based guidelines16 developed by a committee from the American Academy of Family Physicians, the American Academy of Neurology, and other organizations support the use of intravenous metoclopramide (Reglan) and intravenous, intramuscular, and rectal prochlorperazine (Compazine) as single-agent therapies in patients with acute migraine headaches and nausea.

The committee concluded that oral antiemetics and 5-HTBetween 70 and 85 percent of women have nausea during pregnancy, and an estimated 0.5 percent develop hyperemesis gravidarum.17 The pathogenesis of nausea in pregnancy is not completely understood but is thought to be multifactorial.

Treatment of nausea and vomiting ideally involves correcting the underlying cause.

When the exact cause is not known or cannot be corrected, symptoms still can be treated.

This action subsequently decreases afferent visceral and chemoreceptor trigger zone stimulation of the medullary vomiting center.

Because of their diffuse blockade of serotonin, these agents have become the primary treatment for a variety of causes of nausea.

Antihistamine and anticholinergic drugs are relatively inexpensive.

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