Treatment for Cannabinoid Hyperemesis Syndrome
The definitive treatment for cannabinoid hyperemesis syndrome is complete and permanent cessation of cannabis use—this is the only intervention that leads to long-term resolution of symptoms. 1, 2
Acute Management in the Emergency Department
First-Line Pharmacologic Therapies
Haloperidol or droperidol (butyrophenones) should be prioritized as first-line agents because they demonstrate superior efficacy, reducing hospital length of stay by nearly 50% (6.7 vs 13.9 hours, p=0.014) compared to conventional antiemetics. 3, 4
Topical capsaicin 0.1% cream applied to the abdomen provides symptom relief by activating transient receptor potential vanilloid type 1 (TRPV1) receptors and has shown consistent benefit across multiple studies. 1, 2, 3
Benzodiazepines can be effective for their sedating and anxiolytic effects, which address the stress-mediated component of CHS. 1, 3, 4
Second-Line Options
Promethazine and olanzapine (other antipsychotics) may be tried if haloperidol is unavailable or contraindicated. 1, 2
Ondansetron may be attempted but typically has limited efficacy compared to its use in other conditions causing nausea and vomiting. 1, 2
Critical Medications to Avoid
- Opioids must be avoided entirely as they worsen nausea, do not address the underlying pathophysiology, and carry high addiction risk in this population. 1, 2, 3
Non-Pharmacologic Acute Management
Hot showers or baths (hydrothermotherapy) provide temporary symptomatic relief and serve as both a diagnostic clue and therapeutic intervention. 2, 4, 5
Supportive care with intravenous fluids for patients with significant volume depletion. 5
Long-Term Management Strategy
Primary Treatment
- Cannabis cessation counseling is essential and non-negotiable—symptoms resolve only after abstinence for at least 6 months or a duration equal to 3 typical vomiting cycles. 1, 2, 3
Preventive Pharmacotherapy
Tricyclic antidepressants, specifically amitriptyline, are the mainstay of long-term preventive therapy. Start at 25 mg at bedtime and titrate weekly by 25 mg increments to reach the minimal effective dose of 75-100 mg. 1, 2, 3
This approach mirrors the management of cyclic vomiting syndrome, which shares clinical features with CHS. 1
Adjunctive Support
Psychological support and addiction counseling should be provided, as anxiety and depression are common comorbidities in this population. 2, 6
Co-management with psychiatry is recommended for patients with extensive psychiatric comorbidity or treatment resistance. 2
Diagnostic Approach Before Treatment
Clinical Criteria to Confirm CHS
Before initiating treatment, confirm the diagnosis using these criteria established by the American Gastroenterological Association:
Stereotypical episodic vomiting occurring at least 3 times annually with acute onset and duration less than 1 week. 1, 2
Cannabis use pattern of more than 1 year duration before symptom onset, with frequency greater than 4 times per week. 1, 2
Pathognomonic hot water bathing behavior for symptom relief, present in 44-71% of cases. 2, 3
Rule Out Life-Threatening Conditions First
In the ED setting, immediately exclude acute abdomen, bowel obstruction, mesenteric ischemia, pancreatitis, and myocardial infarction before attributing symptoms solely to CHS. 1, 3
Common Pitfalls to Avoid
CHS is frequently underdiagnosed due to limited clinician awareness, leading to extensive unnecessary testing and treatment with ineffective conventional antiemetics. 3, 4, 5
Many patients remain uncertain about the role of cannabis in their symptoms and may continue use despite recurrent episodes, with recidivism rates exceeding 40%. 1
Patients often report that cannabis helps relieve their symptoms, creating a paradoxical situation where they continue the causative agent. 1
Do not rely on conventional antiemetics alone—ondansetron and metoclopramide are consistently ineffective as monotherapy for CHS. 7, 4, 5
Special Considerations
Perioperative Management
Patients with CHS require enhanced prophylactic antiemetic therapy perioperatively due to increased risk for post-anesthesia intractable vomiting. 3
Anticipate higher anesthetic and analgesic requirements in chronic cannabis users. 3
Use multimodal non-opioid analgesia strategies for postoperative pain management. 3