Cyclical vomiting syndrome
This is an uncommon condition in which nausea and vomiting arrive in episodes: for several hours or several days a person is genuinely ill, then it stops…
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Medicines commonly prescribed for Cyclical vomiting syndrome
For informational purposes only. Always consult a doctor before using any medicine.
METOCLOPRAMIDE BASE 5 mg/mL Injectable Solution and Infusion SolutionIllustrative imageDosage form: INJECTABLE, 5 mg/mlActive substance: metoclopramideManufacturer: Laboratorios Basi Industria Farmaceutica S.A.Prescription required
METOCLOPRAMIDE KERN PHARMA 1 mg/ml ORAL SOLUTIONIllustrative imageDosage form: ORAL SOLUTION/SUSPENSION, 1 mg/mlActive substance: metoclopramideManufacturer: Kern Pharma S.L.Prescription required
IMIGRAN NEO 50 mg FILM-COATED TABLETSIllustrative imageDosage form: TABLET, 50 mgActive substance: sumatriptanManufacturer: Glaxosmithkline S.A.Prescription required
This is an uncommon condition in which nausea and vomiting arrive in episodes: for several hours or several days a person is genuinely ill, then it stops dead, and until the next time they are perfectly well. The episodes are copies of one another, and that is how the condition is recognised. The diagnosis is rarely made at once, because the first job is to be sure that nothing else is behind the repeated vomiting. That part has a section of its own below, and it matters more than anything else here.
What an episode looks like
An episode unfolds to the same script every time, and most people eventually recognise the start of it an hour ahead. First comes the warning phase: pallor, a clammy sweat, weakness, rising nausea, an odd sense that something is about to happen. Then the vomiting, repeated and exhausting, often continuing as dry retching once there is nothing left, and frequently beginning at night or in the early hours. After some hours or days it dies away, deep tiredness and sleep follow, and after sleeping the person eats and carries on as if nothing had happened.
An episode is often accompanied by:
- abdominal pain, usually around the navel;
- complete revulsion at food and smells;
- headache, and an inability to tolerate bright light or loud noise;
- loose stools, drooling, a raised temperature without any obvious infection;
- extreme listlessness and dizziness: the person lies facing the wall and does not want to talk.
Two features stand out in particular. One is how stereotyped it is: episodes start at roughly the same time of day and last roughly the same length. The other is complete wellbeing in between, weeks or months without a single complaint. The condition most often begins in preschool children and fades over the years, in many of them giving way to migraine. Adults get it too, and when the episodes start in adult life they tend to be more severe and longer.
What lies behind it
Nobody knows the exact mechanism. The firmest link is with migraine: most children with the syndrome have a close relative with migraine, and the drugs used to prevent migraine help here as well. That is why cyclical vomiting is often described as abdominal migraine. In many people an episode is set off by something recognisable:
- strong emotion, the happy kind as much as the difficult kind: an exam or a row, but equally a birthday, a trip or a celebration;
- lack of sleep, night shifts, flying across time zones;
- physical exhaustion;
- going a long time without food, and dehydration;
- a cold or another infection;
- particular foods and drinks, with chocolate, mature cheeses, caffeine, alcohol and flavour enhancers mentioned most often;
- travel sickness;
- in women, certain days of the cycle.
Triggers are individual, and the only way to identify them is by observation. A diary kept over several months, with the date, the time an episode started, what happened the day before, and how long it lasted, is worth more than any amount of guesswork, and it will be useful to the doctor.
What has to be ruled out
Cyclical vomiting syndrome is a diagnosis of exclusion: it is made once it has been shown that the repeated vomiting is not caused by something else. Here is what is looked for first, and what is worth knowing about yourself.
Regular cannabis use. In teenagers and adults who smoke it heavily and for a long time, a condition develops that looks indistinguishable from cyclical vomiting. There is one giveaway that is almost never wrong: during an episode the person is driven to stand under a very hot shower for long stretches, or to lie in a hot bath, and only that brings any relief. Neither anti-sickness drugs nor intravenous fluids do anything here. It resolves only after cannabis is given up completely, and not immediately but over weeks or months. It is an awkward thing to tell a doctor, and it has to be told: without that detail, treatment can mark time for years.
Surgical causes in children. Green or yellow-green vomit in a child means bile has reached the vomit, and that can be a sign of a volvulus or a bowel obstruction. This is put right in an operating theatre, and on the same day.
Raised pressure inside the skull. A tumour or another mass in the brain causes vomiting that is worse in the mornings and comes with headache, double vision, a squint and unsteadiness. In a child it is worrying if, alongside the episodes, the personality changes, the vision deteriorates or growth slows down.
Metabolic and hormonal disorders. Some rare disorders of metabolism, and adrenal insufficiency, show themselves precisely as episodes of vomiting with weakness, particularly when an episode is triggered by fasting or by an infection. That is why blood tests are done in everyone at the start of the assessment. The stomach and gullet, the bile ducts, the kidneys and the ureters are checked at the same time: a stone or an obstruction to the flow of urine also produces episodes of vomiting with pain.
When to call an ambulance
Call an ambulance, on 112 in Europe, or go straight to an emergency department, if you or your child have any of the following:
- vomit containing blood, or dark vomit resembling coffee grounds;
- green vomit in an adult; yellow-green or green vomit in a child;
- a sudden severe headache, a stiff neck, pain in the eyes from light;
- sudden severe abdominal pain, or an abdomen that is hard or painful to touch;
- skin, lips or tongue that have turned blue, grey, very pale or blotchy; on darker skin this is easier to see on the palms and the soles;
- severe difficulty breathing, gasping, or being unable to get words out; in a baby, wheezing or the belly drawing in under the ribs;
- confusion, unusual drowsiness, a child who is hard to wake or is not responding as usual;
- signs of severe dehydration: a dry mouth, sunken eyes, no tears when crying, little or no urine or urine that is dark, dizziness on standing up.
Do not drive in this situation: ask someone to take you, or call an ambulance. Bring all the medicines you take with you.
Separately, it is worth seeing a doctor without waiting for an emergency if the episodes have changed: become more frequent or longer, started running differently from before, or the gaps between them have stopped being genuinely symptom-free. A change in the handwriting of the illness is a reason to revisit the diagnosis.
How the diagnosis is made
There is no single test that confirms cyclical vomiting. The doctor works from the story, so come prepared: how many episodes there have been, how long each lasted, what time of day they started, what came before them, how long you feel well in between, and what has helped in the past.
Investigations are then arranged to steer away from the dangerous causes: blood and urine tests, an ultrasound scan of the abdomen, endoscopy if needed, and a brain scan where something inside the skull is suspected. How much is done depends on age and on what the examination turns up: a child having a first episode is investigated more thoroughly than an adult with ten years of identical episodes behind them.
What helps
During an episode there is a single aim: to get through it with as little damage as possible.
- A dark, quiet room and sleep; in many people sleep cuts the episode short.
- Drink in small sips and often: water, diluted juice, oral rehydration solutions, which a pharmacist can recommend. Gulping down a glassful achieves nothing, as it all comes back up.
- Medicines the doctor has prescribed in advance for use during an episode are taken as early as possible, right at the start of the warning phase, not at the height of the vomiting.
- If the vomiting cannot be stopped and signs of dehydration appear, hospital is needed: a drip with fluid and glucose is the most reliable way out of it.
If episodes happen more often than once a month, preventive treatment is worth considering. The doctor may prescribe the same drugs used to prevent migraine; the choice depends on age. An anti-sickness medicine and a painkiller for use during an episode are chosen separately, so that they are already in the house.
Routine helps too: do not skip meals or go many hours without food, get enough sleep and at consistent times, drink in hot weather and during exercise, and steer around the triggers you know about. And one practical detail that is easily forgotten: stomach acid eats away at tooth enamel. After vomiting, rinse the mouth with water or with a bicarbonate of soda solution, and leave brushing for at least half an hour, or the brush will wear away the softened enamel. Anyone with frequent episodes should see a dentist more often than usual.
Online consultation
The first and most important step is taken remotely: going through the history of the episodes. The doctor will ask how the whole thing runs, look at your diary, say whether this resembles cyclical vomiting or whether the picture needs another explanation, and draw up a list of investigations. Online is a convenient way to agree a plan for episodes, arrange prevention, and work out what to do when a child is vomiting so that it never reaches the point of a drip. The signs in the ambulance section are not assessed remotely: blood in the vomit, green vomit, sudden abdominal pain or severe dehydration need to be seen immediately.
This material is for information only and does not replace medical advice.
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