What is Cannabinoid Hyperemesis Syndrome (CHS)?

From the Guidelines

Cannabinoid hyperemesis syndrome (CHS) is a condition that can only be definitively treated with complete cessation of cannabis use, as evidenced by the most recent study in 2024 1.

Key Points

• The management of CHS focuses on symptom relief during acute episodes, with the use of IV fluids, antiemetics such as ondansetron or promethazine, and hot showers or baths providing temporary relief 1.
• Topical capsaicin cream (0.1%) applied to the abdomen may also help reduce symptoms, as it activates transient receptor potential vanilloid type 1 receptors 1.
• Benzodiazepines like lorazepam can be used for severe symptoms, but opioids should be avoided due to worsening of nausea and high risk of addiction 1.
• For long-term management, counseling to achieve marijuana cessation and tricyclic antidepressants, such as amitriptyline, are the mainstay of therapy, with the minimal effective dose being 75–100 mg at bedtime 1.

Pathophysiology

• CHS is a disorder of gut–brain interaction, characterized by cyclic vomiting, nausea, and abdominal pain, and is associated with prolonged bathing behavior (long hot baths or showers) 1.
• The endocannabinoid system plays a crucial role in the development of CHS, with the activation of CB1 receptors leading to loss of negative feedback on the hypothalamic–pituitary–adrenal axis, resulting in increased vagal nerve discharges contributing to vomiting 1.

Diagnosis

• CHS should be suspected in patients with chronic nausea and vomiting and cannabis use, and the clinical diagnostic criteria for CHS include cyclic vomiting, nausea, and abdominal pain, as well as prolonged bathing behavior 1.
• The diagnosis of CHS is based on clinical features, cannabis use patterns, and resolution of symptoms after cannabis cessation, as stated in the 2024 study 1.

Treatment

• The only definitive treatment for CHS is complete cessation of cannabis use, which can lead to resolution of symptoms after a period of abstinence for at least 6 months, or at least equal to the total duration of 3 typical vomiting cycles in that patient 1.
• During acute episodes, management focuses on symptom relief, and for long-term management, counseling to achieve marijuana cessation and tricyclic antidepressants are the mainstay of therapy 1.

From the Research

Definition and Diagnosis of Cannabinoid Hyperemesis Syndrome

• Cannabinoid hyperemesis syndrome (CHS) is a syndrome of cyclic vomiting associated with cannabis use 2.
• The diagnostic characteristics of CHS include a history of regular cannabis use, cyclic nausea and vomiting, resolution of symptoms after stopping cannabis, compulsive hot baths with symptom relief, male predominance, abdominal pain, and at least weekly cannabis use 2.
• The pathophysiology of CHS remains unclear, with a dearth of research dedicated to investigating its underlying mechanism 2, 3.

Treatment Options for Cannabinoid Hyperemesis Syndrome

• Supportive care with intravenous fluids, dopamine antagonists, topical capsaicin cream, and avoidance of narcotic medications has shown some benefit in the acute setting 2.
• Cannabis cessation appears to be the best treatment for CHS, with complete resolution of symptoms occurring only after cessation of cannabis use 2, 4.
• Pharmacological management of CHS may include the use of analgesics, antiemetics, antipsychotics, beta blockers, and transient receptor potential vanilloid (TRPV) agonists, as well as hydrothermotherapy and capsaicin 4.
• Benzodiazepines, haloperidol, and capsaicin have been reported as effective treatments for acute CHS, while tricyclic antidepressants may be effective for long-term treatment 5.

Clinical Trajectories and Patterns of Use

• Patients with CHS often experience persistent symptoms, including abdominal pain, nausea, and cyclic vomiting, in the period following an emergency department visit 6.
• Cannabis use frequency and quantity may be reduced immediately after an emergency department visit, but most patients return to pre-visit cannabis use patterns within a few days 6.
• Recurrent emergency department visits for cyclic vomiting are common among patients with CHS, highlighting the need for patient-centered interventions around cannabis use disorder 6.