Cyclic vomiting syndrome
Kids throw up. Most of the time it is in response to a viral or bacteria infection of the GI tract. Typically the child will continue to vomit until the stomach is empty. But sometimes children will continue to dry heave for hours, long after that last meal is long gone. Parents worry about everything. In particular, we worry about our children’s health and nutrition. When a child refuses food or drink and can’t keep anything down, we get really worried.
Imagine that your child starts having regular vomiting episodes every week or two. She throws up her lunch, keeps on vomiting bile, and still her body dry heaves. It happens at least four times an hour and can go on for days before she finally gets any relief. These attacks can disappear as quickly as they start, leaving no trace that your baby was ever so violently ill. Between attacks, she appears healthy. Yet during attacks, she is weak and pale, often requiring IV fluids in the ER. During more than one prolonged episode, she has required hospitalization just to keep her hydrated. You are exhausted and worried. The doctors have done ultrasounds, x-rays, GI scopes, MRIs, and more blood tests than you can count. The fear mounts as test after test comes back negative. Why can’t they find out what is making your baby so sick? Finally, after months of testing, a specialist suggests the problem might not be digestive at all. He calls is “Cyclic vomiting syndrome” and explains that it is a migraine variant. He prescribes a triptan nasal spray to abort the attacks and Periactin to reduce the frequency of attacks. Then he instructs you to start looking for potential triggers.
It can take months or even years to get an accurate diagnosis. Part of the challenge is ruling out gastrointestinal diseases first. Long before you get to a pediatric headache specialist who can properly treat CVS, you will likely spend a lot of time with GI specialists. Once GI problems are ruled out, you may still experience doctors who insist on treating the symptoms as an undiagnosed GI disorder. By disclosing your family history of migraine and sharing your suspicions, you may be able to expedite the diagnostic process.
Criteria from ICHD-3:
A. At least five attacks of intense nausea and vomiting, fulfilling criteria B and C
B. Stereotypical in the individual patient and recurring with predictable periodicity
C. All of the following:
1. nausea and vomiting occur at least four times per hour\
2. attacks last ≥1 hour and up to 10 days
3. attacks occur ≥1 week apart
D. Complete freedom from symptoms between attacks
E. Not attributed to another disorder
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 CVS.
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.
Although most commonly seen in children and adolescents, adult migraineurs can experience cyclic vomiting, too. Any time you or your child have unexplained bouts of vomiting please talk to your doctor. Because there are so many conditions to rule out, the early testing begins, the sooner a diagnosis can be made and treatment started.
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