Cyclic vomiting syndrome

Overview

Cyclic vomiting syndrome is characterized by episodes of severe vomiting that have no apparent cause. Episodes can last for hours or days and alternate with symptom-free periods. Episodes are similar, meaning that they tend to start at the same time of day, last the same length of time, and occur with the same symptoms and intensity.

Cyclic vomiting syndrome occurs in all age groups, though it often begins in children around 3 to 7 years old. Although it's more common in children, the number of cases diagnosed in adults is increasing.

The syndrome is difficult to diagnose because vomiting is a symptom of many disorders. Treatment often involves lifestyle changes to help prevent the events that can trigger vomiting episodes. Medications, including anti-nausea and migraine therapies, may help lessen symptoms.

Symptoms

The symptoms of cyclic vomiting syndrome often begin in the morning. Signs and symptoms include:

• Three or more recurrent episodes of vomiting that start around the same time and last for a similar length of time
• Varying intervals of generally normal health without nausea between episodes
• Intense nausea and sweating before an episode starts

Other signs and symptoms during a vomiting episode may include:

• Abdominal pain
• Diarrhea
• Dizziness
• Sensitivity to light
• Headache
• Retching or gagging

When to see a doctor

Call your doctor if you see blood in your or your child's vomit.

Continued vomiting may cause severe dehydration that can be life-threatening. Call your doctor if you or your child is showing symptoms of dehydration, such as:

• Excess thirst or dry mouth
• Less urination
• Dry skin
• Sunken eyes or cheeks
• No tears when crying
• Exhaustion and listlessness

Causes

The underlying cause of cyclic vomiting syndrome is unknown. Some possible causes include genes, digestive difficulties, nervous system problems and hormone imbalances. Specific bouts of vomiting may be triggered by:

• Colds, allergies or sinus problems
• Emotional stress or excitement, especially in children
• Anxiety or panic attacks, especially in adults
• Certain foods and drinks, such as alcohol, caffeine, chocolate or cheese
• Overeating, eating right before going to bed or fasting
• Hot weather
• Physical exhaustion
• Exercising too much
• Menstruation
• Motion sickness

Identifying the triggers for vomiting episodes may help with managing cyclic vomiting syndrome.

Risk factors

The relationship between migraines and cyclic vomiting syndrome isn't clear. But many children with cyclic vomiting syndrome have a family history of migraines or have migraines themselves when they get older. In adults, cyclic vomiting syndrome is also associated with a personal or family history of migraines.

Chronic use of marijuana (Cannabis sativa) also has been associated with cyclic vomiting syndrome because some people use marijuana to relieve their nausea. However, chronic marijuana use can lead to a condition called cannabis hyperemesis syndrome, which typically leads to persistent vomiting without normal intervening periods. People with this syndrome often demonstrate frequent showering or bathing behavior.

Cannabis hyperemesis syndrome can be confused with cyclic vomiting syndrome. To rule out cannabis hyperemesis syndrome, you need to stop using marijuana for at least one to two weeks to see if vomiting lessens. If it doesn't, your doctor will continue testing for cyclic vomiting syndrome.

Complications

Cyclic vomiting syndrome can cause these complications:

• Dehydration. Excessive vomiting causes the body to lose water quickly. Severe cases of dehydration may need to be treated in the hospital.
• Injury to the food tube. The stomach acid that comes up with the vomit can damage the tube that connects the mouth and stomach (esophagus). Sometimes the esophagus becomes so irritated it bleeds.
• Tooth decay. The acid in vomit can corrode tooth enamel.

Prevention

Many people know what triggers their cyclic vomiting episodes. Avoiding those triggers can reduce the frequency of episodes. While you may feel well between episodes, it's very important to take medications as prescribed by your doctor.

If episodes occur more than once a month or require hospitalization, your doctor may recommend preventive medicine, such as amitriptyline, propranolol (Inderal), cyproheptadine and topiramate.

Lifestyle changes also may help, including:

• Getting adequate sleep
• For children, downplaying the importance of upcoming events because excitement can be a trigger
• Avoiding trigger foods, such as alcohol, caffeine, cheese and chocolate
• Eating small meals and low-fat snacks daily at regular times

Diagnosis

Cyclic vomiting syndrome can be difficult to diagnose. There's no specific test to confirm the diagnosis, and vomiting is a sign of many conditions that must be ruled out first.

The doctor will start by asking about your child's or your medical history and conducting a physical exam. The doctor will also want to know about the pattern of symptoms that you or your child experiences.

After that, the doctor may recommend:

• Imaging studies — such as endoscopy, ultrasound or a CT scan — to check for blockages in the digestive system or signs of other digestive conditions
• Motility tests to monitor the movement of food through the digestive system and to check for digestive disorders
• Laboratory tests to check for thyroid problems and other metabolic conditions

Treatment

There's no cure for cyclic vomiting syndrome, though many children no longer have vomiting episodes by the time they reach adulthood. For those experiencing a cyclic vomiting episode, treatment focuses on controlling the signs and symptoms.

You or your child may be prescribed:

• Anti-nausea drugs
• Pain-relieving medications
• Medications that suppress stomach acid
• Antidepressants
• Anti-seizure medications

The same types of medications used for migraines can sometimes help stop or even prevent episodes of cyclic vomiting. These medications may be recommended for people whose episodes are frequent and long lasting, or for people with a family history of migraine.

IV fluids may need to be given to prevent dehydration. Treatment is individualized based on the severity and duration of symptoms as well as the presence of complications.

Self care

Lifestyle changes can help control the signs and symptoms of cyclic vomiting syndrome. People with cyclic vomiting syndrome generally need to get adequate sleep. Once vomiting begins, it may help to stay in bed and sleep in a dark, quiet room.

When the vomiting phase has stopped, it's very important to drink fluids, such as an oral electrolyte solution (Pedialyte) or a sports drink (Gatorade, Powerade, others) diluted with 1 ounce of water for every ounce of sports drink.

Some people may feel well enough to begin eating a normal diet soon after they stop vomiting. But if you don't or your child doesn't feel like eating right away, you might start with clear liquids and then gradually add solid food.

If vomiting episodes are triggered by stress or excitement, try during a symptom-free interval to find ways to reduce stress and stay calm. Eating small meals and low-fat snacks daily, instead of three large meals, also may help.

Alternative medicine

Alternative and complementary treatments may help prevent vomiting episodes, although none of these treatments has been well studied. These treatments include:

• Coenzyme Q10 (ubiquinone), a natural substance made in the body that is available as a supplement. Coenzyme Q10 assists with the basic functions of cells.
• L-carnitine, a natural substance that is made in the body and is available as a supplement. L-carnitine helps your body turn fat into energy.
• Riboflavin (vitamin B-2), a vitamin found in certain foods and available as a supplement. Riboflavin plays a role in the body's mitochondrial processes.

Coenzyme Q10, L-carnitine and riboflavin may work by helping your body overcome difficulty in converting food into energy (mitochondrial dysfunction). Some researchers believe mitochondrial dysfunction may be a factor causing both cyclic vomiting syndrome and migraine.

Be sure to see a doctor and have the diagnosis of cyclic vomiting syndrome confirmed before starting any supplements. Always check with your doctor before taking any supplements to be sure you or your child is taking a safe dose and that the supplement won't adversely interact with any medications you're taking. Some people may experience side effects from coenzyme Q10 and L-carnitine, including diarrhea and fishy body odor.

Coping and support

Because you never know when the next episode might occur, cyclic vomiting syndrome can be difficult for the whole family. Children may be especially concerned, and may worry constantly that they'll be with other children when an episode happens.

You or your child may benefit from connecting with others who understand what it's like to live with the uncertainty of cyclic vomiting syndrome. Ask your doctor about support groups in your area.

Preparing for your appointment

You're likely to start by seeing your primary care doctor or your child's pediatrician. But you may be referred immediately to a digestive diseases specialist (gastroenterologist). If you or your child is in the middle of a severe vomiting episode, the doctor may recommend immediate medical care.

Here's some information to help you get ready for your appointment and know what to expect from the doctor.

What you can do

• Keep a record of any symptoms, including how often vomiting occurs and any typical triggers you may have noticed, such as food or activity.
• Write down key medical information, including other diagnosed conditions.
• Write down key personal information, including dietary habits and any major stresses or recent changes — both positive and negative — in your child's life or yours.
• Bring a list of all medications, vitamins or supplements that you or your child takes.
• Write down questions to ask the doctor.

Questions to ask the doctor

Some basic questions to ask the doctor include:

• What's the most likely cause of these symptoms?
• Are any tests needed?
• Do you think this condition is temporary or long lasting?
• What treatments do you recommend?
• Is there a medication that can help?
• Are there any dietary restrictions that can help?

Don't hesitate to ask other questions that occur to you during your appointment.

What to expect from the doctor

Be ready to answer questions your doctor may ask:

• When did you or your child begin experiencing symptoms?
• How often does an episode of severe vomiting occur, and how many times do you or does your child typically vomit?
• How long do the episodes typically last?
• Do you or does your child experience abdominal pain?
• Have you noticed any warning signs that an episode is coming, such as loss of appetite or feeling unusually tired, or any common triggers, such as intense emotions, illness or menstruation?
• Have you or has your child been diagnosed with any other medical problems, including mental health conditions?
• What treatments, including over-the-counter medications and home remedies, are you or your child taking for other conditions?
• Does anything seem to improve the symptoms or shorten the duration of an episode?
• Do you or does your child have any history of severe headaches?
• Does anyone in your family have a history of cyclic vomiting syndrome or of migraines?
• Do you or does your child use cannabis in any form? If so, how often?

What you can do in the meantime

The doctor will likely want to see you or your child immediately if an episode of severe vomiting is underway. But if the vomiting has passed, get plenty of rest, drink extra fluids and follow an easy-to-digest diet. It's also a good idea to avoid caffeinated beverages or foods containing caffeine, as these may trigger symptoms.