What is cyclic vomiting syndrome (CVS)?
CVS is characterized by episodes or cycles of severe nausea and vomiting that
last for hours, or even days, that alternate with intervals with no symptoms.
Although originally thought to be a pediatric disease, CVS occurs in all age
groups. Medical researchers believe CVS and migraine headaches are related (see
CVS and Migraine).
Each episode of CVS is similar to previous ones, meaning the episodes tend to
start at the same time of day, last the same length of time, and occur with the
same symptoms and level of intensity. Although CVS can begin at any age, in
children it starts most often between the ages of 3 and 7.
Episodes can be so severe that a person has to stay in bed for days, unable to
go to school or work. The exact number of people with CVS is unknown, but
medical researchers believe more people may have the disorder than commonly
thought. Because other more common diseases and disorders also cause cycles of
vomiting, many people with CVS are initially misdiagnosed until other disorders
can be ruled out. CVS can be disruptive and frightening not just to people who
have it but to family members as well.
The Four Phases of CVS
CVS has four phases:
Symptom-free interval phase.
This phase is the period between episodes when no symptoms are present.
Prodrome phase.
This phase signals that an episode of nausea and vomiting is about to begin. Often marked by nausea —with or without abdominal pain—this phase can last from just a few
minutes to several hours. Sometimes, taking medicine early in the phase can stop
an episode in progress. However, sometimes there is no warning; a person may
simply wake up in the morning and begin vomiting.
Vomiting phase.
This phase consists of nausea and vomiting; an inability to eat, drink, or take medicines without vomiting; paleness; drowsiness; and exhaustion.
Recovery phase.
This phase begins when the nausea and vomiting stop. Healthy color, appetite, and energy return.
What triggers CVS?
Many people can identify a specific condition or event that triggered an
episode, such as an infection. Common triggers in children include emotional
stress and excitement. Anxiety and panic attacks are more common triggers in
adults. Colds, allergies, sinus problems, and the flu can also set off episodes
in some people.
Other reported triggers include eating certain foods such as chocolate or
cheese, eating too much, or eating just before going to bed. Hot weather,
physical exhaustion, menstruation, and motion sickness can also trigger episodes.
What are the symptoms of CVS?
A person who experiences the following symptoms for at least 3 months—with first
onset at least 6 months prior—may have CVS:
- vomiting episodes that start with severe vomiting—several times per hour—and
last less than 1 week
- three or more separate episodes of vomiting in the past year
- absence of nausea or vomiting between episodes
A person with CVS may experience abdominal pain, diarrhea, fever, dizziness, and
sensitivity to light during vomiting episodes. Continued vomiting may cause
severe dehydration that can be life threatening. Symptoms of dehydration include
thirst, decreased urination, paleness, exhaustion, and listlessness. A person
with any symptoms of dehydration should see a health care provider immediately.
How is CVS diagnosed?
CVS is hard to diagnose because no tests—such as a blood test or x ray—can
establish a diagnosis of CVS. A doctor must look at symptoms and medical history
to rule out other common diseases or disorders that can cause nausea and
vomiting. Making a diagnosis takes time because the doctor also needs to
identify a pattern or cycle to the vomiting.
CVS and Migraine
The relationship between migraine and CVS is still unclear, but medical
researchers believe the two are related.
- Migraine headaches, which cause severe head pain; abdominal migraines, which
cause stomach pain; and CVS are all marked by severe symptoms that start and end
quickly and are followed by intervals without pain or other symptoms.
- Many of the situations that trigger CVS also trigger migraines, including stress
and excitement.
- Research has shown that many children with CVS either have a family history of
migraine or develop migraines as they grow older.
Because of the similarities between migraine and CVS, doctors treat some people
with severe CVS with drugs that are also used for migraine headaches. The drugs
are designed to prevent episodes, reduce frequency, and lessen severity.
How is CVS treated?
Treatment varies, but people with CVS generally improve after learning to
control their symptoms. People with CVS are advised to get plenty of rest and
sleep and to take medications that prevent a vomiting episode, stop one in
progress, speed up recovery, or relieve associated symptoms.
Once a vomiting episode begins, treatment usually requires the person to stay in
bed and sleep in a dark, quiet room. Severe nausea and vomiting may require
hospitalization and intravenous fluids to prevent dehydration. Sedatives may
help if the nausea continues.
Sometimes, during the prodrome phase, it is possible to stop an episode from
happening. For example, people with nausea or abdominal pain before an episode
can ask their doctor about taking ondansetron (Zofran) or lorazepam (Ativan) for
nausea or ibuprofen (Advil, Motrin) for pain. Other medications that may be
helpful are ranitidine (Zantac) or omeprazole (Prilosec), which help calm the
stomach by lowering the amount of acid it makes.
During the recovery phase, drinking water and replacing lost electrolytes are
important. Electrolytes are salts the body needs to function and stay healthy.
Symptoms during the recovery phase can vary. Some people find their appetite
returns to normal immediately, while others need to begin by drinking clear
liquids and then move slowly to solid food.
People whose episodes are frequent and long-lasting may be treated during the
symptom-free intervals in an effort to prevent or ease future episodes.
Medications that help people with migraine headaches, such as propranolol
(Inderal), cyproheptadine (Periactin), and amitriptyline (Elavil), are sometimes
used during this phase, but they do not work for everyone. Taking the medicine
daily for 1 to 2 months may be necessary before one can tell if it helps.
The symptom-free interval phase is a good time to eliminate anything known to
trigger an episode. For example, if episodes are brought on by stress or
excitement, a symptom-free interval phase is the time to find ways to reduce
stress and stay calm. If sinus problems or allergies cause episodes, those
conditions should be treated.
During an episode, anti-migraine drugs such as sumatriptan (Imitrex) may be
prescribed to stop symptoms of migraine headache. However, these agents have not
been studied for use in children.
What are the complications of CVS?
The severe vomiting that defines CVS is a risk factor for several complications:
- Dehydration. Vomiting causes the body to lose water quickly. Dehydration can be severe and should be treated immediately.
- Electrolyte imbalance. Vomiting causes the body to lose important salts it needs to keep working properly.
- Peptic esophagitis. The esophagus—the tube that connects the mouth to the stomach—becomes injured from stomach acid moving through it while vomiting.
- Hematemesis. The esophagus becomes irritated and bleeds, so blood mixes with vomit.
- Mallory-Weiss tear. The lower end of the esophagus may tear open or the stomach may bruise from vomiting or retching.
- Tooth decay. The acid in vomit can hurt teeth by corroding tooth enamel.
For More Information
Cyclic Vomiting Syndrome Association
2819 West Highland Boulevard
Milwaukee, WI 53208
Phone: 414.342.7880
Fax: 414.342.8980
Email: cvsa@cvsaonline.org
Internet: www.cvsaonline.org
National Organization for Rare Disorders
55 Kenosia Avenue
P.O. Box 1968
Danbury, CT 06813–1968
Phone: 1.800.999.6673 or 203.744.0100
Fax: 203.798.2291
Email: orphan@rarediseases.org
Internet: www.rarediseases.org
Source: National Institutes of Health; National Institute of Diabetes and Digestive and Kidney Diseases.
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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 12/31/2008...#5973
