Cannabinoid Hyperemesis Syndrome Treatment
Definitive Management
Cannabis cessation is the only definitive cure for CHS and must be strongly recommended as the primary treatment goal. 1, 2 Complete resolution requires at least 6 months of continuous abstinence, or a duration equal to 3 typical vomiting cycles for that specific patient. 1, 2
Acute Episode Management
First-Line Agents
Benzodiazepines (particularly lorazepam) are the most effective acute treatment for nausea and vomiting in CHS based on multiple case series and prospective studies. 3 These work through powerful sedating effects and address the stress-mediated component by modulating the dysregulated hypothalamic-pituitary-adrenal axis. 1, 4
Second-Line Agents
- Haloperidol is the second-line agent for acute symptom control and has demonstrated superior efficacy by reducing hospital length of stay by nearly 50% (6.7 vs 13.9 hours, p=0.014). 5, 3
- Other antipsychotics including promethazine and olanzapine can be effective alternatives. 1, 2
Adjunctive Therapy
- Topical capsaicin 0.1% cream applied to the abdomen activates TRPV1 receptors and provides consistent symptomatic benefit. 1, 5, 2 This works through a completely different mechanism than standard antiemetics. 4
- Hot showers or baths provide temporary relief and serve as a diagnostic clue (present in 71% of CHS patients). 1, 2
Critical Medications to Avoid
Never use opioids in CHS patients—they worsen nausea, carry high addiction risk, and do not address the underlying pathophysiology. 5, 2, 3 Ondansetron may be tried but often has limited efficacy compared to its use in other conditions. 2, 3
Long-Term Preventive Management
Tricyclic antidepressants, specifically amitriptyline, are the mainstay of preventive therapy. 5, 2, 3
Dosing Algorithm:
- Start at 25 mg at bedtime 2, 3
- Titrate weekly by 25 mg increments 3
- Target minimal effective dose of 75-100 mg 5, 2
- Once in remission, taper slowly 6
Emergency Department Approach
Rule Out Life-Threatening Conditions First
Before confirming CHS diagnosis, exclude: 5, 2, 3
- Acute abdomen
- Bowel obstruction
- Mesenteric ischemia
- Pancreatitis
- Myocardial infarction
Diagnostic Criteria (All Three Required)
- Clinical features: Stereotypical episodic vomiting occurring ≥3 times annually 1, 2, 3
- Cannabis use patterns: Duration >1 year before symptom onset AND frequency >4 times per week 1, 2, 3
- Cannabis cessation: Resolution after ≥6 months abstinence or duration equal to 3 typical vomiting cycles 1, 2, 3
Supportive Care
- Intravenous fluid resuscitation for dehydration and electrolyte abnormalities 4, 7
- Avoid exhaustive investigations once CHS is suspected—focus on early diagnosis to facilitate treatment 3
Common Pitfalls
- CHS is frequently underdiagnosed due to limited clinician awareness, leading to extensive unnecessary testing and repeated emergency department visits. 5, 8
- Hot water bathing behavior, while present in 71% of CHS patients, also occurs in 44% of CVS patients and is not pathognomonic. 1, 5
- Standard antiemetics commonly fail in CHS, necessitating mechanistically logical sedating agents. 4
- The diagnostic delay averages several years due to physicians' lack of knowledge. 8
Cannabis Withdrawal Syndrome Considerations
Approximately 47% of regular cannabis users experience withdrawal syndrome after cessation, with symptoms including anxiety, irritability, insomnia, and gastrointestinal distress. 1, 3 Symptom onset occurs within 24-72 hours, peaks between days 2-6, and the acute phase lasts 1-2 weeks. 3 For patients with significant withdrawal symptoms who were consuming high amounts of cannabis, referral to psychiatry or addiction medicine specialists for nabilone or nabiximols substitution is appropriate. 3
Psychological Support
Provide cannabis cessation counseling and psychological support, as anxiety and depression are common comorbidities. 2, 3 Co-management with psychiatry is recommended for patients with extensive psychiatric comorbidity or treatment resistance. 2