Cyclic Vomiting (CV)
Timothy C. Hain, MD Page
December 21, 2014
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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.
CV is infrequent but not rare. In the author's
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).
- "slit ventricle" syndrome in shunted children.
disorders such as aminoacidopathies and organic aciduries
The cause of this syndrome 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).
evaluation with Upper GI/Small bowel follow-through
- MRI of
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 with migraine prevention medications is
sometimes useful, as well as antiemetics. Typically patients are put on a migraine
suppression medication (such as Verapamil), an antimetic (such as Phenergan), with supplementation during acute flareups.
Particularly useful migraine medications
- verapamil or flunarizine
- amitriptyline (used both in children and adults)
- cyproheptadine (used in children)
- sumatriptan and other triptans
- topiramate (but this one can cause some stomach upset by itself)
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.
Particularly useful antiemetics are:
such as Diazepam
- Ondansetron and similar medications
- 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 are not helpful in CV.
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K. (1999). "Electrogastrography in cyclic
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R. D. Murray, et al. (1999). "Is cyclic vomiting syndrome related to
migraine?" J Pediatr134(5):
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April 21, 2015
, Timothy C. Hain, M.D.
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April 21, 2015