Cyclic Vomiting Syndrome (CVS): How Treatment Helps Manage Episodes

Cyclic vomiting syndrome (CVS) is a gastrointestinal condition that involves repeated episodes of severe vomiting. In between these episodes, several weeks or months may pass without symptoms. 

Estimates suggest that about 1% to 2% of U.S. children are affected by cyclic vomiting syndrome. The condition is somewhat less common in adults. However, recent data indicates that more adults may have cyclic vomiting syndrome than previously believed. 

This article reviews everything you need to know about cyclic vomiting syndrome, including symptoms, causes, triggers, treatment options, and more.

Verifying Symptoms of Cyclic Vomiting Syndrome

The primary symptoms of cyclic vomiting syndrome are nausea and vomiting. These symptoms occur in repetitive episodes that tend to start at the same time every day and continue for hours to days at a time. During an episode, you might vomit multiple times per hour.

Other symptoms of cyclic vomiting syndrome include:

• Stomach pain
• Fatigue
• Discolored skin
• Headache
• Appetite loss
• Thirst
• Photosensitivity (light sensitivity)
• Dry retching
• Drooling
• Light-headedness
• Fever
• Diarrhea
• Depressed mood
• Excessive sweating

How Long Does a Cyclic Vomiting Syndrome Episode Last?

From start to finish, a cyclic vomiting syndrome episode may last anywhere from a few hours to 10 days. Typically, every cyclic vomiting syndrome episode starts in a similar way and lasts about the same amount of time. 

Cyclic vomiting syndrome consists of four phases of varying lengths, including:

• Prodrome phase: During the first phase of CVS, you’ll start to feel sick. Your nausea may be accompanied by pale skin, sweating, and/or abdominal pain. This could last just a few minutes or several hours. 
• Vomiting phase: During the vomiting phase, you might vomit up to six times per hour for several hours or up to a week. You may also feel drowsy and as though it’s difficult to move or speak. 
• Recovery phase: Over the next few hours or days, you’ll start to see your symptoms subside as you regain your strength.
• Well phase: After an episode, you may not experience symptoms for a while, ranging from a week to several months.
  

Causes, Risk Factors, and Triggers

The exact cause of cyclic vomiting syndrome remains unknown. However, researchers have identified the following possible causes:

• Genetic mutations related to changes in mitochondrial DNA
• Abnormalities in the brain-gut interaction, especially in response to stress
• Hormonal imbalances
• Dysautonomia (dysfunction in the autonomic nervous system)

Cyclic vomiting syndrome episodes have many possible triggers, including:

• Menstrual cycle changes
• Stress
• Anxiety
• Panic attacks
• Illness
• Temperature changes
• Allergies
• Drinking alcohol
• Caffeine
• Strong emotions, particularly in children 
• Sleep deprivation
• Exhaustion
• Dietary changes, such as fasting, overeating, or eating certain foods (especially chocolate and cheese)

Anyone can develop cyclic vomiting syndrome. However, any of the following risk factors may increase your chance of developing CVS at some point:

• Chronic migraine and/or a family history of migraine
• Autism spectrum disorder (ASD)
• Mental health conditions, such as depression and anxiety
• Motion sickness
• Irritable bowel syndrome (IBS)
• Problems with the autonomic nervous system
• Gastroesophageal reflux disease (GERD)
• Hypertension (high blood pressure)
  

Lags in Diagnosis

It can sometimes take a long time, even years, to receive a diagnosis of cyclic vomiting syndrome. This is partly because cyclic vomiting syndrome is a functional disorder, meaning the gastrointestinal system is dysfunctional without any underlying structural problems. 

To diagnose you with cyclic vomiting syndrome, your healthcare provider will most likely perform a physical examination and ask you about your medical and family histories. They will also inquire about your pattern of symptoms, including how often you’ve had vomiting episodes in the past year and the length of the well-phase window in between each one.

To rule out other possible conditions that could be causing your symptoms, your healthcare provider may also order the following tests:

• Blood and urine tests
• Upper gastrointestinal (GI) endoscopy
• Abdominal ultrasound
• Magnetic resonance imaging (MRI) scans
• Computed tomography (CT) scans
• Gastric emptying study to check for gastroparesis (delayed gastric emptying)
• Upper GI series, which involves fluoroscopy and X-rays

How to Treat Cyclic Vomiting Syndrome Episodes

During an acute cyclic vomiting syndrome episode, your healthcare provider may prescribe the following medications:

• Antiemetic medications, such as Zofran (ondansetron), to treat nausea and vomiting 
• Benzodiazepines, such as Ativan (lorazepam), to treat anxiety symptoms and/or induce sleep
• Pain relief medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), such as Advil (ibuprofen), or opioids, to relieve stomach pain
• Antacids to relieve indigestion

In severe cases, you may need to be hospitalized and given intravenous (IV) fluids to treat dehydration. After an episode ends, it’s important to drink plenty of electrolyte-balancing fluids, such as clear broths or sports drinks. 

To prevent future vomiting episodes, your healthcare provider may prescribe any of the following prophylactic (preventive) medications:

• Tricyclic antidepressants (TCAs), such as Elavil (amitriptyline)
• Antiepileptic medications, such as Topamax (topiramate)
• Medications to treat migraines, such as Inderal (propranolol)
• Certain dietary supplements, such as riboflavin or levocarnitine (L-carnitine)

Beginning CVS Phase: Minimizing Symptoms

When you feel a cyclic vomiting syndrome episode coming on, you should rest in a cool, dark room. To avoid worsening your symptoms, avoid excessive stimulation to the nervous system. This includes physical activity, bright lights, and loud noises. If you can keep them down, drink plenty of fluids—in small sips—to stay hydrated. 

Your healthcare provider may also prescribe medication to stop a vomiting episode from worsening or shorten its length. If you have chronic migraines or a family history of migraines, selective serotonin receptor agonists, such as Imitrex (sumatriptan), may help to stop a cyclic vomiting syndrome episode in its tracks if you take it early enough.

Complications From Recurrent Vomiting

If left untreated, cyclic vomiting syndrome can lead to several complications, including:

• Gastroparesis
• Dehydration
• Tooth damage and decay
• Esophagitis (inflammation of the esophagus)
• Esophageal tears
• Tearing in the upper stomach

Cyclic Vomiting Syndrome in Childhood and Into Adulthood: Symptom Management

You may be able to prevent cyclic vomiting syndrome episodes for yourself or your child by taking the following steps:

• Managing stress and treating anxiety as early as possible
• Learning about and avoiding your/your child’s triggers
• Treating any underlying medical causes, such as allergies
• Making rest and quality sleep a priority

The following dietary changes may also help to reduce the frequency and severity of cyclic vomiting syndrome episodes:

• Reducing caffeine and alcohol intake
• Eating small snacks throughout the day between meals
• Not skipping meals
• Avoiding cheese, chocolate, and foods that contain monosodium glutamate (MSG), especially if they tend to trigger episodes for you
  

Summary

Cyclic vomiting syndrome (CVS) is a condition that causes periodic episodes of severe nausea, vomiting, and indigestion. Between episodes, weeks or months often go by without incident. A cyclic vomiting syndrome episode consists of four phases.

Symptoms such as nausea, stomach pain, and excessive sweating begin to appear during the initial prodrome phase. This is followed by the vomiting phase, during which you may throw up several times every hour for multiple consecutive days. You’ll start to feel better during the recovery phase, and symptoms subside during the well phase, which may last for up to several months. 

Treatment options for cyclic vomiting syndrome include bed rest and prescription medications, whether taken during the vomiting episode or on a prophylactic basis.