From the Guidelines
Cyclical vomiting syndrome (CVS) should be managed with a combination of preventive and acute treatment strategies, including daily medications like amitriptyline, topiramate, or propranolol, and anti-nausea medications like ondansetron, promethazine, or chlorpromazine, to reduce episode frequency and alleviate symptoms, as recommended by the most recent guidelines 1.
Symptoms of Cyclical Vomiting Syndrome
The symptoms of CVS include:
- Intense nausea
- Persistent vomiting (up to 5-6 times per hour)
- Abdominal pain
- Headache
- Sensitivity to light
- Dizziness
- Fatigue Episodes may be triggered by stress, lack of sleep, certain foods, menstruation, or infections 1.
Treatment of Cyclical Vomiting Syndrome
Treatment involves both preventive and acute management strategies. For prevention, daily medications like:
- Amitriptyline (10-100 mg at bedtime)
- Topiramate (25-200 mg twice daily)
- Propranolol (10-80 mg twice daily) can reduce episode frequency 1. During an acute episode, treatment focuses on anti-nausea medications such as:
- Ondansetron (4-8 mg every 6 hours)
- Promethazine (12.5-25 mg every 6 hours)
- Chlorpromazine (10-25 mg every 6 hours) along with IV fluids for dehydration 1. Sedatives like lorazepam (0.5-2 mg) may help with anxiety and sleep.
Lifestyle Modifications
Lifestyle modifications are crucial, including:
- Regular sleep patterns
- Stress management techniques
- Avoiding trigger foods
- Staying well-hydrated Patients should keep a symptom diary to identify triggers and establish an emergency treatment plan with their healthcare provider for quick intervention when episodes begin 1. CVS is believed to involve brain-gut dysfunction and may be related to migraine mechanisms, which explains why antimigraine medications are often effective in prevention 1.
From the Research
Symptoms of Cyclical Vomiting Syndrome
- Cyclic vomiting syndrome (CVS) is a disorder characterized by episodes of nausea and vomiting lasting for 1-5 days followed by asymptomatic periods 2
- CVS is generally classified as having four phases: prodromal, acute/vomiting/hyperemesis, recovery, and remission/interepisodic 2
- CVS affects both children and adults with a prevalence of approximately 2% in the United States, and is more common in female individuals and affects all races 3
- The pathophysiology of CVS is unknown and a combination of genetic, environmental, autonomic, and neurohormonal factors is believed to play a role 3
- CVS is also closely associated with migraine headaches and likely have a shared pathophysiology 3, 4
Treatment for Cyclical Vomiting Syndrome
- Current management strategies include trigger avoidance, abortive and prophylactic medication therapies, and supportive care 2
- Antidepressant, antiepileptic, and antimigraine medications show an overall reduction or remission of CVS symptoms in more than 70% of patients 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 is extremely important to improve overall patient outcomes, including screening and treatment for anxiety, depression, migraine headache, autonomic dysfunction, sleep disorders, and substance use 3, 5
- Techniques like meditation, relaxation, and biofeedback may be offered as complementary therapy to improve overall well-being and patient care outcomes 5
Diagnosis of Cyclical Vomiting Syndrome
- The diagnosis of CVS is based on the Rome criteria, and minimal recommended testing includes an upper endoscopy and imaging studies of the abdomen 3
- Some diagnostic tests of exclusion remain essential, including an upper gastrointestinal (GI) contrast study to exclude intestinal malrotation and basic laboratory screening 4
- An abdominal ultrasound is recommended to exclude renal hydronephrosis in children and biliary disease in adults 4
- Exclusion of metabolic/genetic conditions is warranted in those with specific warning signs, presentation in infants/toddler age, and in those with refractory disease 4