What are the treatment options for motion sickness in adults and children?

Motion Sickness Treatment

For adults, use scopolamine transdermal patch as first-line therapy, applied 6-8 hours before anticipated motion exposure, or meclizine 12.5-25 mg three times daily if scopolamine is contraindicated; for children over 6 years, use dimenhydrinate at weight-appropriate doses, while avoiding all antihistamines in children under 6 years due to safety concerns. 1, 2

First-Line Treatment for Adults

Scopolamine (Anticholinergic Agent)

• Apply a 1.5 mg transdermal patch behind the ear at least 6-8 hours before motion exposure, with each patch providing protection for approximately 3 days 1
• Scopolamine blocks acetylcholine in the central nervous system, reducing the neural mismatch that causes motion sickness 1
• Elderly patients require close monitoring for anticholinergic side effects including confusion, urinary retention, and increased fall risk 1
• Scopolamine passes into breast milk, so consider interrupting breastfeeding or selecting alternative medication in nursing mothers 1

Meclizine (First-Generation Antihistamine)

• Dose: 12.5-25 mg three times daily for adults who cannot use scopolamine due to contraindications or side effects 1
• Meclizine suppresses the central emetic center and prevents motion sickness symptoms in approximately 40% of susceptible individuals compared to 25% with placebo 2, 3
• Sedation occurs in approximately 66% of patients, which is a common limiting side effect 2
• Anticholinergic effects include blurred vision and cognitive impairment 2

Severe or Refractory Cases in Adults

Combination Therapy

• Use scopolamine transdermal patch plus meclizine together when severe symptoms require combination therapy, as they provide complementary mechanisms of action 1

Alternative Agents for Severe Symptoms

• Promethazine 12.5-25 mg can be used for severe cases requiring rapid onset, though it carries more side effects including hypotension, respiratory depression, and extrapyramidal effects 1
• Ondansetron 8 mg every 4-6 hours (sublingual formulation preferred) may be considered, though obtain a baseline ECG first due to QTc prolongation risk 1
• Note that ondansetron showed no benefit over placebo in highly susceptible subjects in research studies 4

Agents to Avoid

• Do not use benzodiazepines for motion sickness due to lack of efficacy and significant harm potential 1

Treatment for Children

Age-Specific Safety Guidelines

• Children under 6 years should NOT receive over-the-counter antihistamines for motion sickness due to potential toxicity—between 1969 and 2006, there were 69 fatalities associated with antihistamines in children under 6 years 2
• The FDA advisory committees have recommended against using OTC antihistamines in children under 6 years based on safety concerns and reported fatalities 2

Children Over 6 Years

• Dimenhydrinate is FDA-approved for prevention and treatment of nausea, vomiting, or vertigo of motion sickness and can be used at weight-appropriate doses 5
• First-generation antihistamines prevent motion sickness symptoms in approximately 40% of susceptible individuals 2
• Watch for paradoxical behavioral disinhibition, especially in younger children, when using antihistamines 2
• Monitor closely for sedation (occurs in ~66% of patients) and anticholinergic side effects 2

Non-Pharmacological Approaches for Young Children

• For children who cannot take antihistamines, use distraction techniques, audio-visual entertainment, and relaxation methods first 2

Special Populations

Pregnant Women

• Paracetamol (acetaminophen) is first-line despite relatively poor efficacy 6
• Dimenhydrinate is considered safe first-line pharmacologic antiemetic therapy if non-pharmacologic measures fail during pregnancy 2
• NSAIDs can only be used during the second trimester 6
• Metoclopramide can be used for nausea associated with motion sickness in pregnancy 6

Breastfeeding Women

• Paracetamol is preferred, though ibuprofen is also considered safe 6
• Scopolamine passes into breast milk—consider interrupting breastfeeding or selecting alternative medication 1

Critical Pitfalls to Avoid

Long-Term Use

• Do not use vestibular suppressant medications long-term, as they interfere with central compensation in peripheral vestibular conditions and prevent natural adaptation to motion 1, 2, 7

Medication Combinations

• Avoid combining multiple motion sickness medications, which can lead to overdose errors and increased risk of adverse effects 2

Aspirin in Children

• Never give aspirin or aspirin-containing products to children ≤18 years with nausea/vomiting due to Reye's syndrome risk 2

Anticholinergics in Elderly

• Anticholinergic medications are an independent risk factor for falls in elderly patients—use with extreme caution and close monitoring 1

Adjunctive Measures

Behavioral Modifications

• Position in the most stable part of the vehicle, watch the true visual horizon, steer the vehicle when possible, or lie down with eyes closed 8
• Slow, intermittent exposure to motion can reduce symptoms through habituation 8

Second-Line Adjuncts

• Metoclopramide (prokinetic antiemetic) can be a useful adjunct for managing nausea and vomiting 7
• Prochlorperazine may be used for short-term management of severe nausea or vomiting in severely symptomatic patients 7