What Is Cyclic Vomiting Syndrome?

Cyclic vomiting syndrome (CVS), sometimes referred to as abdominal migraine, tends to occur during childhood. It causes episodes of recurrent nausea and vomiting, persisting for several hours, days, or weeks, usually with a resolution of symptoms between the episodes. The condition can be associated with a trigger, such as stress, fatigue, or infection. Children who experience cyclic vomiting may have similar additional episodes months or years later.

A key feature of CVS is that it is not caused by a disease of the gastrointestinal (GI) system. It is estimated to affect about 2% of school-aged children.

Child throwing up in bucket
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What Is Cyclic Vomiting Syndrome?

The prominent effect of CVS is episodic bouts of nausea and vomiting that recur periodically, usually in association with a trigger that is not necessarily related to the GI system.

The most common age at which CVS begins is between the ages of 3 and 7 and it is more common among girls than boys. Most children who experience the condition will outgrow it during adolescence. But CVS symptoms can continue throughout adolescence and into adulthood and it may start at any age.

Cyclic Vomiting Syndrome Symptoms

Children with CVS usually have episodes or cycles of nausea, vomiting, and gagging that last between a few hours to a few weeks. Children might gag while brushing their teeth, looking at food, thinking about food, or smelling food.

During an episode, children may also have decreased activity and a decreased appetite. They may also want to stay home and away from other kids due to fear of embarrassment in case they vomit in front of their peers.

Unless a child also has an infection, the symptoms of CVS are not accompanied by symptoms of an infection, such as fever, diarrhea, pain, or respiratory symptoms.

Symptoms that can accompany nausea and vomiting in CVS include:

  • Abdominal discomfort
  • Headache
  • Pale skin
  • Sunken eyes due to dehydration

Once the episode is over, children are usually symptom-free until the next time it happens.

When to Get Help

Usually, CVS is not dangerous. But you need to get urgent medical attention if your child has any of the following signs:

  • Severe dizziness
  • Unable to walk unassisted
  • Fainting
  • Vomiting blood
  • Decreased responsiveness, cannot be easily woken up
  • Seizures or convulsions

Phases of Cyclic Vomiting Syndrome

The episodes of CVS progress through several phases. Sometimes, as a child or their parents begins to recognize the phases, it can be easier to avoid triggers or to get some rest so that an episode might not be as severe.

Phases include:

  • Prodrome: A child might feel sick, dizzy, or mildly nauseated.
  • Vomiting: The child will have nausea, vomiting, gagging, and might be unable to keep down food and drink.
  • Recovery: Your child might start to feel better, with an increased appetite, but still might not feel fully recovered.
  • Well phase: There are no symptoms of CVS, although your child might avoid certain foods or other triggers.

Causes

It is believed that CVS is caused by a disturbance of GI function that could be mediated by the brain and by hormones.

Most children with this condition have a family history of migraines and many experts believe the two are related. In fact, CVS is often treated with Periactin (cyproheptadine) or Elavil (amitriptyline), which are also used to treat pediatric migraines.

Triggers

Usually, CVS is precipitated by certain triggers. Generally, a child who has CVS will be sensitive to specific triggers, and not to others.

  • Stress can trigger an episode of CVS. Sometimes children and their parents might not recognize that a child is experiencing stress, with CVS being the only symptom.
  • Being tired, sleepy, or jet-lagged may precipitate a cycle of nausea and vomiting.
  • Certain odors, especially a smell associated with a disliked food, can trigger an episode.
  • Motion sickness, which can be caused by riding in a car, airplane, boat, or roller coaster.
  • While CVS is not viral gastroenteritis ("stomach flu"), sometimes a child can experience cyclic vomiting during or after stomach flu.

Diagnosis

Cyclic vomiting syndrome is classified as a functional GI disorder. The symptoms are due to dysfunction of the digestive system, not due to a structural problem.

The diagnosis is made by the typical pattern of symptoms, especially the fact that there are long periods without any symptoms at all. There aren't any specific tests that can confirm the diagnosis.

Diagnostic testing during a CVS evaluation is done to rule out the possibility of other conditions—such as organic disorders that have a structural basis.

Tests that may be done include:

  • Brain imaging tests, such as computerized tomography (CT) scan or magnetic resonance imaging (MRI)
  • Metabolic tests
  • Abdominal ultrasound
  • Upper gastrointestinal X-ray with small bowel follow-through (UGI-SBFT)

Sometimes the diagnosis and treatment of this condition go hand in hand, as a response to treatments helps to confirm the diagnosis.

Conditions that can cause similar symptoms, but without the normal in between episodes include:

  • Inborn errors of metabolism
  • Malrotation of the intestine with volvulus, a condition where the bowel moves around and becomes tangled

Treatment

The treatment of CVS during the acute phase differs from treatment during the chronic phase. Acute treatment is focused on preventing problems such as dehydration. Long-term treatment is focused on preventing the recurrence of episodes.

Children with cyclic vomiting also appear to have a somewhat increased risk of anxiety disorders. You can consider whether treatment for anxiety (such as counseling) would be beneficial for your child.

Very rarely, a Mallory Weiss tear in the esophagus can result from violent vomiting episodes and may cause hematemesis (vomiting blood). If your child is vomiting blood, their pediatrician will likely refer them to a gastroenterologist.

Acute Treatment

The main complication of cyclic vomiting is dehydration, which sometimes results in the need for hospitalization and IV fluids.

Treatments may include:

  • Resting in a quiet, dark room
  • IV fluids if the child is dehydrated
  • Medications such as Zofran (ondansetron), Imitrex (sumatriptan), Catapres (clonidine), or benzodiazepines which can prevent nausea and vomiting

During an acute episode of vomiting, treatment is aimed at making your child as comfortable as possible.

Chronic Treatment

The best treatment for cyclic vomiting is prevention. If your child is diagnosed with cyclic vomiting, you may want to attempt to identify triggers that provoke these episodes.

Medications that are used for preventing cyclic vomiting—often with very good results—include:

  • Periactin (cyproheptadine)
  • Inderal (propanolol)
  • Elavil (amitryptylline)

Avoiding Triggers

Keeping a vomiting journal just as some people keep a headache journal to keep track of migraine triggers, may help you identify the factors that precede your bouts of CVS so you can avoid them, if possible.

Common Triggers

Triggers for cyclical vomiting episodes include:

  • Stress
  • Excitement
  • Infections
  • Eating certain foods
  • Hot weather
  • Motion sickness

The Role of Riboflavin

Research has investigated the possibility of using the B vitamin riboflavin for the prevention of cyclic vomiting. It's known that riboflavin is sometimes helpful in the prevention of migraine headaches. Riboflavin is found in whole grains as well as almonds, spinach, and mushrooms.

A small European study in 2016 found that treating children who had been diagnosed with CVS with riboflavin for 12 months helped to improve the condition. While this study is far too small to guide treatment at this time, it may be helpful to ask your pediatrician if the addition of this vitamin to your child's treatment plan could be beneficial.

A Word From Verywell

Most children who have CVS do very well and outgrow their symptoms. There have not been any recorded deaths from the syndrome, though children do sometimes end up needing hospitalization for treatment of dehydration.

One study found that over half of children who outgrew the symptoms of cyclic vomiting went on to have migraine headaches.

Make a point to learn more about migraine headaches in children, as they are often different from those in adults. And while your child is coping with CVS, make sure you are familiar with the symptoms of dehydration in children and how to manage vomiting in children.

Frequently Asked Questions (FAQs)

What causes chronic vomiting? Chronic vomiting can be caused by a GI disturbance, hormones, and/or triggered by the brain. In CVS, cyclic vomiting is considered to be caused by hormones and by the brain, although there is not a dangerous underlying medical problem associated with it.

How do you stop constant vomiting? You can stop vomiting by avoiding the triggers that tend to precipitate it (such as certain odors). Your doctor may also prescribe medications for you to prevent nausea and vomiting.

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