From the Guidelines
Cyclic vomiting syndrome (CVS) should be managed with a combination of preventive medications, acute interventions, and lifestyle modifications to reduce episode frequency and improve quality of life, as supported by the most recent evidence from 2024 1.
Diagnosis and Management
Cyclic vomiting syndrome is a chronic disorder characterized by episodes of nausea, vomiting, and retching, separated in time by episode-free periods. The diagnosis of CVS is often delayed, and patients may experience extensive and futile investigations, and even unnecessary surgical procedures. However, early recognition and appropriate treatment can reduce CVS symptoms, reduce healthcare utilization, and improve patients' quality of life 1.
Treatment Approaches
For prevention, tricyclic antidepressants like amitriptyline (starting at 10-25mg at bedtime, gradually increasing to 50-100mg if needed) or anticonvulsants such as topiramate (25-100mg twice daily) are commonly used. During acute episodes, antiemetics like ondansetron (4-8mg every 6 hours) or promethazine (12.5-25mg every 6 hours) can help control vomiting. Intravenous fluids are often necessary to prevent dehydration 1.
Lifestyle Modifications
Patients should identify and avoid personal triggers such as stress, lack of sleep, or specific foods. Lifestyle modifications including regular sleep patterns, stress management techniques, and small, frequent meals can help reduce episode frequency. Some patients benefit from supplementation with coenzyme Q10 (100-200mg daily) or L-carnitine (50-100mg/kg/day divided into 2-3 doses) 1.
Key Considerations
CVS is believed to involve autonomic nervous system dysfunction and may be related to migraine pathways, which explains why antimigraine medications are often effective. Early intervention at the first sign of an episode can sometimes abort or reduce its severity. Recognition of the various CVS phases is essential, and patient education on this point is imperative to optimal care 1.
Clinical Features
The hallmark of CVS is recurrent, acute episodes of vomiting and retching, with many patients experiencing prodromal symptoms, lasting a median of 1 hour, before the onset of vomiting. Abdominal pain is present in most patients during a CVS episode and should not preclude a diagnosis of CVS 1.
From the Research
Definition and Characteristics of Cyclic Vomiting Syndrome
- Cyclic vomiting syndrome (CVS) is a disorder characterized by recurrent and unpredictable episodes of intense vomiting, interspersed with periods of apparent wellbeing 2.
- CVS is a chronic disorder of gut-brain interaction characterized by recurrent disabling episodes of nausea, vomiting, and abdominal pain 3.
- The syndrome affects both children and adults, with a prevalence of approximately 2% in the United States, and is more common in female individuals 3.
Pathophysiology and Triggers
- The exact etiology of CVS remains unknown, but genetic factors, nervous system alterations, autonomic dysregulation, and environmental factors (such as the use and abuse of cannabinoids) are postulated as possible triggers 2.
- A combination of genetic, environmental, autonomic, and neurohormonal factors is believed to play a role in the pathophysiology of CVS 3.
- CVS is closely associated with migraine headaches and likely shares a similar pathophysiology 3, 4.
Diagnosis and Diagnostic Challenges
- There is no specific test for confirming the presence of CVS, and diagnosis is based on the Rome criteria 3.
- Minimal recommended testing includes an upper endoscopy and imaging studies of the abdomen 3.
- A thorough evaluation of symptoms and the ruling out of other possible causes of recurrent vomiting are required for diagnosis 2.
Management and Treatment
- Management of CVS typically involves a multidisciplinary approach, including pharmacologic options, behavioral, and psychologic support therapies 2.
- Prophylactic therapy consists of tricyclic antidepressants (amitriptyline), antiepileptics (topiramate), and aprepitant in refractory patients 3, 5.
- Abortive therapy consists of triptans, antiemetics (ondansetron), and sedation 3, 5.
- Treatment of comorbid conditions, such as anxiety, depression, and autonomic dysfunction, is extremely important to improve overall patient outcomes 3, 5.