Cyclical Vomiting Syndrome: The Essentials

Cyclical Vomiting Syndrome is one of the episodic syndromes that may be associated with Migraine. It is most often seen in children. Although less common, adults can experience it, too. Cyclical Vomiting Syndrome is characterized by periodic attacks of vomiting. It can take months or even years to get an accurate diagnosis. Part of the challenge is ruling out gastrointestinal diseases first. Disclosing a family history of Migraine may expedite the diagnostic process.

Treatment

As with Migraine, treatment is multifaceted. Acute medications are used to abort the attacks. Preventives reduce the frequency and severity of attacks. Rescue treatments reduce symptoms and prevent more serious complications (i.e. dehydration). Trigger identification and avoidance, lifestyle management, dietary changes, and stress management all play an important role in the management of Cyclical Vomiting Syndrome.

Patients are advised to avoid skipping meals, stay well-hydrated, and get regular adequate sleep. When an attack occurs, triptans can be used to shorten attack duration. Anti-emetics and diphenhydramine are also used to control nausea and vomiting. If these measures do not stop the vomiting and it goes on for several days, IV fluids in the ER may be required. First line preventives are Elavil (amitriptyline), Inderal (propranolol) or Periactin. As with migraine, beta blockers, anti-epileptics, antidepressants, or calcium channel blockers can also be tried. Some new studies recommend supplementing with CoQ10 and L-carnitine, too.

ICHD-3 Diagnostic Criteria:

Description:

Recurrent episodic attacks of intense nausea and vomiting, usually stereotypical in the individual and with predictable timing of episodes. Attacks may be associated with pallor and lethargy. There is complete resolution of symptoms between attacks.

Diagnostic criteria:

1. At least five attacks of intense nausea and vomiting, fulfilling criteria B and C
2. Stereotypical in the individual patient and recurring with predictable periodicity
3. All of the following:
   • nausea and vomiting occur at least four times per hour
   • attacks last for 1 hour or longer, up to 10 days
   • attacks occur 1 week or more apart
4. Complete freedom from symptoms between attacks
5. Not attributed to another disorder.

Note:

In particular, history and physical examination do not show signs of gastrointestinal disease.

Comment:

1.6.1.1 Cyclic vomiting syndrome is typically a self-limiting episodic condition occurring in childhood, with periods of complete normality between episodes. The cyclic nature is the hallmark, and attacks are predictable.

This disorder was first included as a childhood periodic syndrome in ICHD-II. The clinical features of this syndrome resemble those found in association with migraine headaches, and multiple threads of research over the last years have suggested that 1.6.1.1 Cyclic vomiting syndrome is a condition related to migraine.

Sources:

1. International Headache Society (IHS) (2018). 1.6.1.1 Cyclical Vomiting Syndrome/ (n.d.). Retrieved April 23, 2018, from https://www.ichd-3.org/1-migraine/1-6-episodic-syndromes-that-may-be-associated-with-migraine/1-6-1-recurrent-gastrointestinal-disturbance/1-6-1-1-cyclical-vomiting-syndrome/