Chronic vomiting syndrome (CVS) is a common, chronic functional GI disorder with episodic nausea, vomiting, and often, abdominal pain. Symptoms can be distressing, and prompt diagnosis and therapy is important. CVS is associated with many conditions such as migraine, anxiety and depression. Medications such as amitriptyline are effective in preventing CVS, but side effects hinder their use. Cannabis is frequently used by patients for symptom relief but use of high potency products may cause worsening of symptoms or reveal symptoms in genetically predisposed individuals.
People who have mild disease (fewer than four episodes/year, episodes lasting up to 2 days, quick recovery from episodes, or episodes not requiring emergency department (ED) care or hospitalization) are usually prescribed medications. These medications are best given in the early stages of an attack and can prevent progression to vomiting. Medications used for preventing episodes include sumatriptan (20 mg intranasal or 6 mg subcutaneous), ondansetron (8 mg beneath the tongue), and diphenhydramine (25-50 mg). This combination can help abort symptoms and potentially avoid ED visits or hospitalizations.
People with moderate-to-severe CVS are offered medication to prevent episodes in addition to therapy to stop episodes. Recent guidelines recommend tricyclic antidepressants (TCAs) such as amitryptyline to prevent CVS episodes. Amitriptyline should be started at 25 mg at night and gradually increased up by 10-25 mg each week to prevent side effects. An EKG should be checked to monitor cardiac side effects. Unfortunately, side effects from TCAs are quite common and include cognitive impairment, drowsiness, dryness of mouth, weight gain, constipation, and mood changes, which may result in dose reduction or discontinuation.
Medically Reviewed by Onikepe Adegbola, MD PhD.
1. Stanghellini V et al. Gastroenterology. 2016;150:1380-92.
2. Aziz I et al. Clin Gastroenterol Hepatol. 2019 Apr;17(5):878-86.
3. Kovacic K et al. Curr Gastroenterol Rep. 2018;20(10):46.
4. Zaki EA et al. Cephalalgia. 2009;29:719-28.
5. Venkatesan T et al. BMC Gastroenterol. 2014;14:181.
6. Ellingsen DM et al. Neurogastroenterol Motil. 2017;29 (6)e13004 9.
7. Venkatesan T et al. Neurogastroenterol Motil. 2016;28:1409-18.
8. Wasilewski A et al. Am J Gastroenterol. 2017;112:933-9.
9. van Sickle MD et al. Am J Physiol Gastrointest Liver Physiol 2003;285:G566-76.
10. Parker LA et al. Br J Pharmacol. 2011;163:1411-22.
11. van Sickle MD et al. Gastroenterology. 2001;121:767-74.
12. Fleisher DR et al. BMC Med. 2005;3:20.
13. Kumar N et al. BMC Gastroenterol. 2012;12:52.
14. Li BU et al. J Pediatr Gastroenterol Nutr. 2008;47:379-93.
15. Bhandari S et al. Clin Auton Res. 2018 Apr;28(2):203-9.
16. Venkatesan T et al. Neurogastroenterol Motil. 2019;31 Suppl 2:e13604. doi: 10.1111/nmo.13604.
17. Sagar RC et al. Neurogastroenterol Motil. 2018;30. doi: 10.1111/nmo.13174.
18. Taranukha T et al. Neurogastroenterol Motil. 2018 Apr;30(4):e13245. doi: 10.1111/nmo.13245.
19. Bhandari S and Venkatesan T. Dig Dis Sci. 2017;62:2035-44.
20. Choung RS et al. Neurogastroenterol Motil. 2012;24:20-6, e21. doi: 10.1111/j.1365-2982.2011.
21. Bhandari S et al. Intern Med J. 2019 May;49(5):649-55.
22. Venkatesan T et al. Exp Brain Res. 2014; 232:2563-70.
23. Venkatesan T et al. Clin Gastroenterol Hepatol. 2019 Jul 25. doi: 10.1016/j.cgh.2019.07.039.
24. Simonetto DA et al. Mayo Clin Proc. 2012;87:114-9.
25. Wallace EA et al. South Med J. 2011;104:659-64.
26. Allen JH et al. Gut. 2004;53:1566-70.
27. Venkatesan T et al. Neurogastroenterol Motil. 2019;31 Suppl 2:e13606. doi: 10.1111/nmo.13606.
28. Habboushe J et al. Basic Clin Pharmacol Toxicol. 2018;122:660-2.
29. Bhandari S and Venkatesan T. Curr Treat Options Gastroenterol. 2016;14:495-506.
30. Hikita T et al. Cephalalgia. 2011;31:504-7.
31. Fuseau E et al. Clin Pharmacokinet 2002;41:801-11.
32. Hejazi RA et al. J Clin Gastroenterol. 2010;44:18-21.
33. Sezer OB and Sezer T. J Neurogastroenterol Motil. 2016;22:656-60.
34. Cristofori F et al. Aliment Pharmacol Ther. 2014;40:309-17.
Antiepileptics such as topiramate, mitochondrial supplements such as Coenzyme Q10 and riboflavin are alternative medications to prevent CVS. Aprepitant, a newer medication, has been found to be effective in treatment of CVS that does not respond to any other measures. In addition to pharmacotherapy, addressing other conditions such as anxiety and depression and counseling patients to abstain from heavy cannabis use is also important.
Medically reviewed by Onikepe Adegbola, MD PhD