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Section IconHaloperidol
Overview
Haloperidol is a first-generation antipsychotic medication traditionally used in the treatment of psychosis, mood disorders, Tourette syndrome, and intractable nausea and vomiting.
Evidence for its analgesic properties was first discussed in the 1970s. Recent studies support these findings.
Haloperidol can be administered orally, intravenously, intramuscularly, or subcutaneously.
Indications
First-line or add-on therapy for:
  • Gastroparesis
  • Migraine
  • Cannabinoid hyperemesis syndrome
  • Palliative pain control, nausea, and vomiting
  • Chronic pain syndromes unrelieved by other analgesic modalities
Novel indications for analgesia:
  • Abdominal migraines
  • Cancer pain, chemotherapy/radiation-induced emesis
  • Neuropathic pain
  • Opioid-induced hyperalgesia
Contraindications
Comatose states from any cause
Known allergy or hypersensitivity to haloperidol
Parkinsonism
Severe intoxication with ETOH or other CNS depressants
Equipment & Dosing
Nausea/vomiting/gastroparesis: 0.5 to 2 mg IV OR 2 to 5 mg IM/PO
Pain adjunct: 2 to 5 mg IV OR 5 to 10 mg IM/PO
Decanoate formulation should be administered IM only. Select route-appropriate formulation.
Complications
Anticholinergic symptoms: dry mouth, constipation, blurred vision
Extrapyramidal symptoms: akathisia, Parkinsonism, tardive dyskinesia, dystonia
Hypotension
Neuroleptic malignant syndrome
QT prolongation (IV administration increases the risk)
Sedating effects
Charting & Documentation
Because haloperidol is relatively novel for pain and nausea/vomiting, document the rationale for its use and ideally that you discussed its use with patient (risk vs benefit).
Chart ECG in appropriate cases (see below).
Special Considerations
Patients with a history of heart disease or prolonged QTc and those taking QTc-prolonging medications should get an ECG before administration. Consider telemetry.
Use caution with patients taking anticonvulsants or with known seizure disorder. Haloperidol can lower the seizure threshold.
It is considered high risk in geriatrics (patients older than 65 years) per Beers criteria.
There is evidence of increased mortality in elderly patients with dementia-related psychosis.
Caution in pregnancy.
Avoid in women who are nursing.
References
  1. Gaffigan ME, Bruner DI, Wason C, et al. A randomized controlled trial of intravenous haloperidol vs. intravenous metoclopramide for acute migraine therapy in the emergency department. J Emerg. Med. 2015 Sep;49(3):326–34.
  2. Maltbie AA, Cavenar JO Jr, Sullivan JL, et al. Analgesia and haloperidol: a hypothesis. J Clin Psychiatry. 1979 Jul;40(7):323–6.
  3. Ramirez R, Stalcup P, Croft B, et al. Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department. Am J Emerg Med. 2017 Aug;35(8):1118–20.
  4. Seidel S, Aigner M, Ossege M, et al. Antipsychotics for acute and chronic pain in adults. Cochrane Database Syst Rev. 2013 Aug 29;(8):CD004844.pub3/full.
  5. Shir Y, Shenkman Z, Kaplan L. Neuropathic pain unrelieved by morphine, alleviated by haloperidol [Abstract]. Harefuah. 1990 Apr 15;118(8):452–4.
  6. Witsil JC, Mycyk MB. Haloperidol a novel treatment for cannabinoid hyperemesis syndrome. Am J Ther. 2017 Jan/Feb;24(1):e64–e67.
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