Cyclic Vomiting Syndrome
People who have cyclic vomiting syndrome experience periods of severe nausea and
vomiting that last for hours or days, alternating with symptom-free periods. Diagnosis
necessitates the presence of at least three episodes in the past 6 months or at least five
attacks over any interval and absence of symptoms in between these episodes.
This condition occurs in people of all ages, and onset usually occurs between the ages 3
and 7 years. Females are slightly more likely to have cyclic vomiting syndrome than
males. A relationship between cyclic vomiting syndrome and migraine headaches may
exist. Diagnosis is difficult and is generally made by ruling out other possible conditions.
What are the phases of cyclic vomiting syndrome?
The four phases of cyclic vomiting syndrome are the symptom-free phase, the prodrome
phase, the vomiting phase, and the recovery phase.
The symptom-free interval phase
This is the period between episodes.
The prodrome phase
This is the period right before vomiting begins. Nausea usually is present. For some
people, taking medication can help to prevent vomiting. Some people do not experience
this phase and have no warning of impending vomiting.
The vomiting phase
This period is marked by nausea, vomiting, inability to take nutrition or medications,
pallor, lethargy, and exhaustion. The person often will vomit several times per hour (the
median is six times/hour) and may experience abdominal pain, diarrhea, fever, dizziness,
and sensitivity to light. If medical care is not sought, severe dehydration can occur. This
period usually lasts 1 to 4 days. Some patients have episode-associated hypertension and
elevated adrenocorticotropin hormone.
The recovery phase
Normal color, appetite, and energy return during this phase.
What can trigger cyclic vomiting syndrome?
The following can trigger cyclic vomiting syndrome:
 Emotional stress
 Excitement
 Anxiety
 Illness
 Allergies
 Consumption of certain foods, most commonly:
– A high-protein meal
– Chocolate
– Monosodium glutamate (MSG)
– Caffeine
– Alcohol
– Hot dogs
– Cheese
 Eating too much or eating right before bedtime
 Hot weather
 Overexercising/physical exhaustion
 Menstruation
 Motion sickness
Should I keep a diary?
It is recommended that people with cyclic vomiting syndrome keep a diary to record
intervals between episodes, time of onset and ending, what was eaten before getting sick,
and aggravating life events. These diaries can identify potentially avoidable triggers in
75% of pediatric patients. In one small study, 88% of children with documented food
sensitivity to cow, soy, or egg-white proteins improved after eliminating specific foods
from their diets. If it seems that attacks are induced by fasting, high-carbohydrate snacks
between meals, before physical activity, and at bedtime may help.
Are medications helpful?
Antimigraine medications, such as Imitrex®, are sometimes used during vomiting
episodes. Antiemetics, H2 receptor antagonists, pain medications, sedatives, and proton
pump inhibitors commonly are prescribed during attacks. If substantial fluid and/or
electrolyte deficits are found, some health professionals recommend the use of 10%
dextrose and 0.9% sodium-chloride replacement fluid for hospitalized individuals.
Parenteral nutrition providing adequate calories and 1.5 grams of protein/kilogram of
body weight can help to reverse the catabolism following an episode of vomiting. Shortacting angiotensin converting enzyme (ACE) inhibitors are used for hypertension in
patients who present with hypertension only during vomiting episodes. Fluid restriction
sometimes is necessary for patients with secretion of antidiuretic hormone with
hyponatremia, low serum osmolality, and high urine specific gravity. Water and
electrolyte replacement are crucial during the recovery phase.
Migraine headache medications (such as Inderal®, Periactin®, and Elavil®) sometimes are
used during symptom-free periods. Beta-blockers, tricyclic antidepressants, and
anticonvulsants are also sometimes used for cyclic vomiting syndrome.
Some medical professionals have used L-carnitine, amitriptyline, and coenzyme Q10 for
treatment of cyclic vomiting syndrome, although limited data is available proving
efficacy. Young girls with menstrual-related episodes sometimes are prescribed lowestrogen oral contraceptives. Acupuncture at the pericardial point and psychotherapy
(especially for stress reduction) also may prove beneficial.
Complications of cyclic vomiting syndrome include peptic esophagitis, hematemesis,
Mallory-Weiss tear, and tooth decay.
References and recommended readings
Boles RG, Lovett-Barr MR, Preston A, Li BU, Adams K. Treatment of cyclic vomiting
syndrome with co-enzyme Q10 and amitriptyline, a retrospective study.
http://www.cvsaonline.org/pdfs/Co-Q10%20&%20Amitriptyline%20Article.pdf.
Accessed May 1, 2013.
Cyclic vomiting syndrome. Cyclic Vomiting Syndrome Association Web site.
http://www.cvsaonline.org/pdfs/What%20is%20CVS.pdf. Accessed May 1, 2013.
Cyclic vomiting syndrome. National Digestive Diseases Information Clearinghouse
(NDDIC) Web site. http://digestive.niddk.nih.gov/ddiseases/pubs/cvs/. Accessed May 1,
2013.
Li BU, Lefevre F, Chelimsky GG, et al; North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition. North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition consensus statement on the diagnosis and
management of cyclic vomiting syndrome. J Pediatr Gastroenterol Nutr.
2008;47(3):379-393. doi:10.1097/MPG.0b013e318173ed39.
Review Date 5/13
K-0652