What should I do if I have vomiting and stomach ache that worsen at night?

Vomiting and Stomach Ache Worse at Night

For vomiting and stomach ache that worsen at night, start with metoclopramide 10-20 mg taken 30 minutes before your evening meal and again at bedtime, combined with lifestyle modifications including elevating the head of your bed and avoiding food 3 hours before sleep. 1, 2

Immediate Assessment Priorities

Before starting treatment, you need to determine if this requires urgent evaluation:

• Seek immediate medical attention if you have: bilious (green/yellow) vomiting, bloody vomit, severe abdominal pain with a bent-over posture, inability to keep down any fluids, or signs of dehydration 1, 3
• Red flag symptoms requiring same-day evaluation: persistent vomiting preventing oral intake, severe pain, fever, or altered mental status 1, 4

Initial Laboratory Testing

If symptoms persist beyond a few days, obtain:

• Complete blood count, serum electrolytes, glucose, liver function tests, lipase, and urinalysis to exclude metabolic causes and assess dehydration 1
• Consider testing for hypercalcemia, thyroid function, and pregnancy (if applicable) 1
• Cannabis use screening is critical - Cannabis Hyperemesis Syndrome commonly presents with symptoms worse at night and early morning 1

First-Line Pharmacologic Treatment

Start dopamine receptor antagonists scheduled around-the-clock, not as-needed:

• Metoclopramide 10-20 mg four times daily (30 minutes before meals and at bedtime) is the preferred first-line agent, as it both treats nausea and promotes gastric emptying 1, 2
• Alternative: Prochlorperazine 5-10 mg every 6 hours 1, 5
• Take medications with food and with your largest meal of the day to minimize nausea 6
• Some patients prefer taking the dose at bedtime to avoid daytime nausea burden 6

Nighttime-Specific Interventions

Since your symptoms worsen at night, add these targeted measures:

• Add nighttime H2 receptor antagonist (such as famotidine 20-40 mg at bedtime) for nocturnal acid control 6
• Alginate antacids (such as Gaviscon) taken after your evening meal and at bedtime are particularly effective for nighttime symptoms and post-prandial symptoms 6
• Elevate the head of your bed by 6-8 inches using blocks under the bed frame (not just pillows) 6
• Avoid eating within 3 hours of bedtime 6

Second-Line Treatment if Symptoms Persist After 4 Weeks

If symptoms continue despite the above measures:

• Add ondansetron 4-8 mg every 8-12 hours (a 5-HT3 antagonist) 1, 5
• Monitor for QTc prolongation, especially if taking other medications 1
• Consider adding lorazepam 0.5-1 mg at bedtime if anxiety contributes to symptoms 5

Supportive Care Measures

• Ensure fluid intake of at least 1.5 liters daily to prevent dehydration 1
• Eat small, frequent meals rather than large meals 1, 5
• Cold foods may be better tolerated than hot foods with strong aromas 5
• Consider thiamin supplementation if vomiting has been prolonged to prevent Wernicke's encephalopathy 1

When to Obtain Imaging

• One-time upper endoscopy (EGD) or upper GI imaging is recommended if symptoms persist beyond 4 weeks to exclude obstructive lesions, ulcers, or gastritis 1
• Avoid repeated endoscopy unless new symptoms develop 1
• Plain abdominal X-ray during acute severe episodes can exclude bowel obstruction 6

Critical Pitfalls to Avoid

• Never use antiemetics if you suspect bowel obstruction (severe distension, no bowel movements, severe cramping pain) - this can mask dangerous progression 1
• Do not take metoclopramide if you are a young male without discussing extrapyramidal side effect risks with your physician 1, 5
• Correct electrolyte abnormalities (especially potassium and magnesium) before they become severe - prolonged vomiting causes hypokalemia and metabolic alkalosis 1
• If using cannabis, cessation is required for definitive diagnosis - treatments can still help even with ongoing use, but 6 months of abstinence may be needed for resolution 1

Reassessment Timeline

• Reassess symptoms within 24-48 hours of starting treatment 5
• If no improvement after 3-6 weeks of optimized treatment, proceed to imaging studies and consider referral to gastroenterology 6, 1
• Monitor for medication side effects: sedation, constipation (from ondansetron), or movement disorders (from metoclopramide) 1, 5