Acute Extrapyramidal Reaction Following Metoclopramide Administration

Case at a Glance

A 30-year-old female with multiple comorbidities developed severe akathisia and panic symptoms following intravenous metoclopramide administration in the emergency department.

Patient's Story

The patient presented to the emergency department with acute visual disturbances. Given her history of migraines, the attending physician administered intravenous metoclopramide (Reglan) as part of the diagnostic workup to rule out migraine-related etiology. Within minutes of administration, the patient experienced an unprecedented panic response characterized by severe agitation, uncontrollable vocalization, and aggressive behavior. She attempted to leave the treatment area despite security intervention and experienced involuntary bowel incontinence. The acute episode was followed by persistent lower extremity muscle fasciculations and tachycardia.

Initial Assessment

Patient is a 30-year-old female, 100 lbs, 5'1", with medical history significant for tethered spinal cord syndrome, bronchial asthma, and chronic migraines. Current medications include galcanezumab (Emgality), ubrogepant (Ubrelvy), and vortioxetine (Trintellix). Vital signs during the acute episode showed tachycardia and hypertension consistent with sympathetic hyperactivation.

The Diagnostic Journey

The constellation of symptoms—acute onset of severe agitation, motor restlessness, and involuntary movements following metoclopramide administration—strongly suggested an extrapyramidal reaction, specifically akathisia. The patient's low body weight may have contributed to increased drug sensitivity. Laboratory workup was unremarkable, ruling out metabolic causes of agitation.

Final Diagnosis

Acute extrapyramidal reaction (akathisia) secondary to metoclopramide administration, with associated panic response and autonomic hyperactivation.

Treatment Plan

Immediate administration of diphenhydramine (Benadryl) 25-50mg IV to counteract the extrapyramidal effects. Supportive care including cardiac monitoring and reassurance. Patient education regarding metoclopramide intolerance and importance of medical alert documentation.

Outcome and Follow-up

Patient showed significant improvement within 2 hours of diphenhydramine administration. Motor symptoms and tachycardia gradually resolved over 8-12 hours as the metoclopramide was metabolized. Drug allergy was documented in patient's medical record with instructions for alternative antiemetic agents in future treatments. Patient was advised to maintain a personal medical alert card and inform all healthcare providers of this drug intolerance.