What is the best treatment for dry heaves?

Treatment of Dry Heaves (Retching Without Productive Vomiting)

Immediate Rehydration – First Priority

Begin oral rehydration solution (65–70 mEq/L sodium, 75–90 mmol/L glucose) immediately, as dehydration—not the retching itself—drives morbidity and mortality. 1

• Prescribe 2,200–4,000 mL total fluid intake per day, with the rate exceeding ongoing losses (urine output + 30–50 mL/hour insensible losses + any vomit volume). 1
• For mild dehydration (slight thirst, mildly dry mucous membranes), give 50 mL/kg ORS over 2–4 hours. 1
• For moderate dehydration (loss of skin turgor, dry mucous membranes), give 100 mL/kg ORS over 2–4 hours. 1
• Switch to intravenous isotonic fluids (lactated Ringer's or normal saline) immediately if the patient cannot tolerate oral intake, shows altered mental status, or has signs of severe dehydration (prolonged skin tenting >2 seconds, cool extremities, decreased capillary refill). 1

Antiemetic Pharmacotherapy – After Rehydration

Once adequate hydration is established, administer antiemetic agents to control retching and nausea.

• Ondansetron (5-HT₃ antagonist) is effective for chemotherapy-induced and postoperative nausea/vomiting; consider 4–8 mg IV/PO every 8 hours. 2
• Metoclopramide (dopamine antagonist and prokinetic) 10–20 mg PO/IV every 6–8 hours may be used, particularly when gastroparesis or delayed gastric emptying is suspected. 2, 3
• Haloperidol (dopamine antagonist) 0.5–2 mg IV/PO every 6–8 hours is an alternative when other antiemetics fail. 2
• Corticosteroids (e.g., dexamethasone 4–8 mg IV/PO daily) can be added if nausea/vomiting persists despite first-line agents. 2
• Lorazepam (benzodiazepine) 0.5–2 mg IV/PO every 6–8 hours may be beneficial when anxiety or anticipatory nausea contributes to symptoms. 2

Multiple concurrent antiemetics with different mechanisms of action are often required; consider around-the-clock dosing rather than PRN administration. 2

Dietary Modifications

• Resume small, light meals as soon as retching subsides; avoid fatty, heavy, spicy foods and caffeine. 1
• If gastroparesis is suspected (early satiety, postprandial fullness, bloating), recommend small-volume, low-fat, low-fiber meals consumed frequently throughout the day. 3

Rule Out Underlying Causes

Dry heaves may signal serious conditions that require specific intervention:

• Gastroparesis: Consider if symptoms include early satiety, postprandial fullness, and bloating; confirm with gastric emptying study; treat with prokinetics (metoclopramide, erythromycin) and dietary modification. 3
• Rumination syndrome: Suspect if effortless regurgitation occurs within minutes of eating without nausea or retching; diagnose with high-resolution manometry combined with impedance; treat with cognitive behavioral therapy targeting secondary psychological mechanisms. 4, 5
• Gastroesophageal reflux disease (GERD): If heartburn or regurgitation accompanies retching, trial a proton pump inhibitor (e.g., omeprazole 20–40 mg daily). 2, 6
• Bowel obstruction: If abdominal distention, severe cramping, or inability to pass stool/gas is present, obtain plain abdominal radiography or CT scan; nasogastric tube decompression and surgical consultation may be required. 2
• Electrolyte abnormalities: Check serum sodium, potassium, calcium, and glucose; correct hypercalcemia, hypokalemia, or hypoglycemia. 2
• Brain metastases or increased intracranial pressure: Consider neuroimaging if altered mental status, headache, or focal neurologic signs are present. 2
• Medication-induced: Review recent medications (opioids, chemotherapy, antibiotics); consider opioid rotation if patient is on chronic opioids. 2

When Symptoms Persist Despite Initial Management

• Reassess for missed diagnoses: Repeat physical examination, check for abdominal tenderness, distention, or signs of obstruction. 2
• Consider continuous IV/subcutaneous infusion of antiemetics if oral/intermittent dosing fails. 2
• Add alternative therapies such as acupuncture or, in refractory cases with terminal illness, palliative sedation. 2
• Consult or refer to specialized palliative care services or gastroenterology if symptoms remain uncontrolled. 2

Critical Pitfalls to Avoid

• Never prioritize antiemetics over rehydration—dehydration causes the morbidity, not the retching itself. 1
• Never use loperamide or other antimotility agents for dry heaves—these are contraindicated in nausea/vomiting and may worsen symptoms or precipitate complications. 7
• Never delay evaluation for bowel obstruction if abdominal pain, distention, or inability to pass stool is present—plain radiography or CT scan should be obtained promptly. 2
• Never assume dry heaves are benign—they may herald gastroparesis, rumination syndrome, GERD, or serious metabolic/structural abnormalities requiring specific treatment. 3, 4, 5