What non-opiate pain relief options can be given to a patient experiencing cyclical vomiting?

Non-Opiate Pain Relief for Cyclic Vomiting Syndrome

For acute abdominal pain during cyclic vomiting syndrome episodes, use IV ketorolac as first-line non-narcotic analgesia, as opioids worsen nausea and carry addiction risk. 1

Acute Episode Pain Management

IV ketorolac is the recommended first-line non-opiate analgesic when patients present to the emergency department with severe abdominal pain during the emetic phase of CVS. 1, 2 This NSAID provides effective pain control without the nausea-exacerbating effects of opioids, which are particularly problematic in a condition already characterized by uncontrollable vomiting.

Ketorolac Dosing

• 15-30 mg IV every 6 hours (maximum 5 days of use, daily maximum 120 mg) 3
• Administer in combination with aggressive IV fluid replacement and antiemetics 1

Important Caveats for NSAID Use

Exercise caution with ketorolac in high-risk patients, as NSAIDs carry specific toxicity risks that must be weighed against the need for pain control: 3

• Renal toxicity risk: Patients over 60 years, those with compromised fluid status (common in CVS due to dehydration), or receiving nephrotoxic chemotherapy 3
• GI toxicity risk: Patients over 60 years, history of peptic ulcer disease, or significant alcohol use (≥2 drinks daily) 3
• Bleeding risk: Thrombocytopenia or bleeding disorders 3
• Discontinue NSAIDs if BUN or creatinine doubles or if hypertension develops or worsens 3

Comprehensive Pain Management Strategy

The pain management approach should be integrated with the overall CVS treatment protocol:

During Emergency Department Presentation

1. Place patient in quiet, dark room to minimize sensory stimulation, as patients in the emetic phase are agitated and hypersensitive 1, 2
2. IV ketorolac for pain 1
3. Ondansetron 8 mg IV every 4-6 hours as first-line antiemetic 1, 4
4. IV dextrose-containing fluids for rehydration and metabolic support 1
5. IV benzodiazepines for sedation if needed 1, 2

For Refractory Cases

Droperidol or haloperidol can be used as dopamine antagonists when initial therapy fails, though these primarily target nausea rather than pain. 2

Alternative Non-Opiate Approaches

While not specifically analgesics, these medications help reduce the overall symptom burden including pain:

• Sedation with benzodiazepines (lorazepam, alprazolam) can help truncate episodes and reduce pain perception 1
• Promethazine 12.5-25 mg oral/rectal every 4-6 hours or prochlorperazine 5-10 mg every 6-8 hours provide antiemetic effects that may indirectly reduce abdominal discomfort 1

Critical Clinical Pitfall

Do not underestimate CVS severity—approximately one-third of adults with CVS become disabled, and the abdominal pain is equally disabling as the vomiting itself. 2 Aggressive treatment of pain is warranted, but opioids should be avoided as they worsen the primary symptom (nausea/vomiting) and carry addiction risk in a population already vulnerable to substance use disorders. 1

Prophylactic Considerations

For patients with moderate-severe CVS (≥4 episodes/year lasting >2 days), amitriptyline 25-150 mg nightly as prophylactic therapy can reduce episode frequency and severity, thereby preventing pain episodes altogether. 1 This tricyclic antidepressant has a 67-75% response rate and should be the cornerstone of long-term management. 1, 2