From the Guidelines
Tricyclic antidepressants, such as amitriptyline, are the mainstay of therapy for long-term management of cyclic vomiting syndrome (CVS), with a minimal effective dose of 75–100 mg at bedtime. Several medications are available to treat CVS, targeting different aspects of the condition. For acute episodes, antiemetics like ondansetron, promethazine, or olanzapine can help control vomiting 1. During severe episodes, intravenous fluids and medications may be necessary.
Medication Options
- Antiemetics: ondansetron, promethazine, olanzapine
- Tricyclic antidepressants: amitriptyline, starting at 25 mg and titrating the dose with increments each week to reach minimal effective dose of 75–100 mg at bedtime 1
- Topical capsaicin (0.1%) cream can be applied with close monitoring of efficacy and adverse effects 1
Important Considerations
- Opioids should be avoided due to worsening of nausea and high risk of addiction 1
- Treatment should be individualized based on symptom patterns, triggers, and comorbidities, with medication adjustments made according to response and tolerability
- The clinical approach in the emergency department (ED) is different, requiring immediate evaluation for life-threatening disorders, such as acute abdomen, bowel obstruction, mesenteric ischemia, pancreatitis, and myocardial infarction, among others 1
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Medications for Cyclic Vomiting Syndrome (CVS)
The following medications are available for the treatment of CVS:
- Antidepressant medications, such as amitriptyline, which have been shown to reduce or remit CVS symptoms in over 70% of patients 2
- Antiepileptic medications, which have been used to treat CVS, particularly in patients with a history of seizures or epilepsy 2
- Antimigraine medications, such as sumatriptan, which have been shown to be effective in aborting acute vomiting episodes 3, 4
- Cyproheptadine, which is recommended for children under 5 years of age as a prophylactic medication 5, 3
- Propranolol, which has been shown to be useful in children with CVS 5, 4
- NK1 antagonists, which are a new prophylactic approach for CVS 5
- Aprepitant, which can be considered for abortion of an acute vomiting episode when vomiting is refractory to initial treatments 3
- Ondansetron, which is recommended for abortion of an acute vomiting episode, often in combination with sumatriptan 3
- Sedative agents, which can be used to truncate severe episodes of CVS 5
Prophylactic Medications
Prophylactic medications are used to prevent or reduce the frequency and severity of CVS episodes. These include:
- Amitriptyline, which is a standard of care for prophylaxis in children and adults 2, 3
- Cyproheptadine, which is recommended for children under 5 years of age 5, 3
- Tricyclic antidepressants, which have been shown to be effective in reducing the frequency and duration of CVS episodes in both adults and children 4
Abortive Medications
Abortive medications are used to treat acute vomiting episodes. These include:
- Sumatriptan, which has been shown to be effective in aborting acute vomiting episodes 3, 4
- Ondansetron, which is recommended for abortion of an acute vomiting episode, often in combination with sumatriptan 3
- Aprepitant, which can be considered for abortion of an acute vomiting episode when vomiting is refractory to initial treatments 3