Cyclic Vomiting (CV) and Benign Recurrent Vertigo

Timothy C. Hain, MD •Page last modified: August 23, 2020

You may also be interested in our many other pages on migraine on this site• This page discusses cyclic vomiting and benign recurrent vertigo. Recurrent vertigo in general.

Emesis English Vomiting Taxi
(From NASA Symposium) The English are familiar with vomiting (source: https://www.drugs.smd.qmul.ac.uk/drugs/html5/Anti-emetics/AN-FEF54A37-6289-402B-E208-9284E183608A.html) In Chicago, we are so familiar with vomiting that our taxi's include a vomit clean-up fee ($50 in 2017)

Introduction:

Cyclic vomiting consists of spells of uncontrollable vomiting, typically every two or three months (Fleisher et al, 1993). The vomiting can occasionally be so severe as to be lethal. The cause of this syndrome is not entirely certain, but may be migraine. Treatment with migraine prevention medications is sometimes useful as well as with general antiemetics.

A very similar but less severe symptom complex goes under the name of benign recurrent vertigo (BRV). There is also some overlap with basilar artery migraine (BAM), and there is also a large differential to recurrent vertigo.

Epidemiology:

CV is infrequent but not rare. In the author's medical practice, which largely includes adults with dizziness, it is encountered about 1/month (about 2% of caseload). It occurs both in adults and children (Aanpreung et al, 2002). It may occur in as many as 1.9% of school age children (Li et al, 2000). It's characteristics in adults and children are simlar (Prakash, 2001).

Pathophysiology/differential diagnosis:

Cyclic vomiting is most commonly attributed to migraine. However there are many other theories (Forbes et al, 1995). Abnormal gastrointestional motility (low motility) can be found in persons with this syndrome even between vomiting spells (Abell et al, 1988). Higher than normal motility is found after eating (Chong et al, 1999). Cyclic vomiting can also occur in overshunted children (Coker et al, 1987). Occasional reports suggest a mitochondrial abnormality or a hypothalamic syndrome (similar to Klein Levin syndrome).

Approach:

Cyclic vomiting is a diagnosis of exclusion. Most patients initially see a gastroenterologist where disorders such as reflux, gastric malrotation (volvulus) are excluded. In general, in about 40% of patients an underlying etiology is found ( Li et al, 1998), and in the majority of children, migraine is the presumed cause (Li et al, 1999)

According to Olson (2002), a upper GI/Small bowel follow-through followed by a trial of migraine prophylactic therapy is the most effective approach in children. The purpose of the UGSBF is to diagnose volvulus (gastrointestinal obstruction).

Treatment:

Treatment with migraine prevention medications is sometimes useful, as well as antiemetics. Typically patients are put on a migraine suppression medication (such as Verapamil), an antiemetic (such as Phenergan), with supplementation during acute flareups. For the milder BRV variant, our usual treatment approach is found here.

Particularly useful migraine medications are:

  1. verapamil or flunarizine
  2. amitriptyline (used both in children and adults)
  3. cyproheptadine (used in children)
  4. Propranolol or other beta blockers.
  5. sumatriptan and other triptans (e.g. frovatriptan) -- there is no literature establishing that this is helpful however.
  6. topiramate (but this one can cause some stomach upset by itself)

(Aanpreung et al, 2003; Anderson et al, 1997; Benson et al, 1995; Forbes et al, 1995; Kothare et al, 2005; Hikita et al, 2012)

Many of these medications decrease gastrointestional motility, which would seem to contradict the idea that this condition is due to decreased motility. The author has not attempted treatment with topiramate, depakote or similar medications. Similarly, the author has had no experience with treatment of cyclic vomiting with venlafaxine, a very good migraine prevention medication.  Treatment with other triptans than sumatriptan seems reasonable to try but we are unsure if they work. .

Particularly useful antiemetics are:

  1. Phenergan
  2. Benzodiazepines such as Diazepam
  3. Ondansetron and similar medications
  4. Domperidone (Motilium)

A general review of anti-emetic treatment can be found here.

The author has had no success at all using medications that increase gastrointestional motility (e.g. metoclopramide), but erythromycin is advocated by some( Vanderhoof et al, 1993).  We have encountered one patient who responded to biaxin, a related medication.

Van Calcar et al (2002) reported that L-Carnitine (50 mg/kg) is an effective treatment. We have had no experience.

Anticonvulsants, in general, are not helpful in CV but of course topiramate is used in CV and it is an anticonvulsant.

References:

  1. Aanpreung, P. and C. Vajaradul (2002). "Cyclic vomiting syndrome in Thai children." J Med Assoc Thai. 85 Suppl 2: S743-8.
  2. Abell, T. L., C. H. Kim, et al. (1988). "Idiopathic cyclic nausea and vomiting--a disorder of gastrointestinal motility?" Mayo Clin Proc63(12): 1169-75.
  3. Andersen, J. M., K. S. Sugerman, et al. (1997). "Effective prophylactic therapy for cyclic vomiting syndrome in children using amitriptyline or cyproheptadine." Pediatrics100(6): 977-81.
  4. Benson, J. M., S. L. Zorn, et al. (1995). "Sumatriptan in the treatment of cyclic vomiting." Ann Pharmacother29(10): 997-9.
  5. Boles, R. G. (2011). "High degree of efficacy in the treatment of cyclic vomiting syndrome with combined co-enzyme Q10, L-carnitine and amitriptyline, a case series." BMC Neurol 11: 102
  6. Chong, S. K. (1999). "Electrogastrography in cyclic vomiting syndrome." Dig Dis Sci44(8 Suppl): 64S-73S.
  7. Coker, S. B. (1987). "Cyclic vomiting and the slit ventricle syndrome." Pediatr Neurol3(5): 297-9
  8. Fleisher, D. R. and M. Matar (1993). "The cyclic vomiting syndrome: a report of 71 cases and literature review." J Pediatr Gastroenterol Nutr17(4): 361-9.
  9. Forbes, D. (1995). "Differential diagnosis of cyclic vomiting syndrome." J Pediatr Gastroenterol Nutr21 Suppl 1: S11-4.
  10. Kothare, S. V. (2005). "Efficacy of flunarizine in the prophylaxis of cyclical vomiting syndrome and abdominal migraine." Eur J Paediatr Neurol 9(1): 23-26.
  11. Forbes, D. and G. Withers (1995). "Prophylactic therapy in cyclic vomiting syndrome." J Pediatr Gastroenterol Nutr21 Suppl 1: S57-9.
  12. Hikita, T., H. Kodama, et al. (2011). "Sumatriptan as a treatment for cyclic vomiting syndrome: a clinical trial." Cephalalgia 31(4): 504-507.
  13. Li, B. U. and J. P. Balint (2000). "Cyclic vomiting syndrome: evolution in our understanding of a brain-gut disorder." Adv Pediatr47: 117-60.
  14. Li, B. U., R. D. Murray, et al. (1998). "Heterogeneity of diagnoses presenting as cyclic vomiting." Pediatrics102(3 Pt 1): 583-7.
  15. Li, B. U., R. D. Murray, et al. (1999). "Is cyclic vomiting syndrome related to migraine?" J Pediatr134(5): 567-72.
  16. Olson, A. D. and B. U. Li (2002). "The diagnostic evaluation of children with cyclic vomiting: a cost-effectiveness assessment." J Pediatr141(5): 724-8.
  17. Prakash, C., A. Staiano, et al. (2001). "Similarities in cyclic vomiting syndrome across age groups." Am J Gastroenterol96(3): 684-8.
  18. Van Calcar, S. C., C. O. Harding, et al. (2002). "L-carnitine administration reduces number of episodes in cyclic vomiting syndrome." Clin Pediatr (Phila)41(3): 171-4.
  19. Vanderhoof, J. A., R. Young, et al. (1993). "Treatment of cyclic vomiting in childhood with erythromycin." J Pediatr Gastroenterol Nutr17(4): 387-91.