Cyclic Vomiting Syndrome in Adults: Clinical Features and Response to Tricyclic Antidepressants

Background and aim Episodic syndromes that may be associated with migraine are a group of disorders affecting patients with migraine or with an increased risk of presenting it, and likely represent an early life expression of migraine. Cyclic vomiting syndrome and benign paroxysmal torticollis are well characterized and represent a frequent cause of request for specialist consultations. The aim of this study is to longitudinally assess the rate of headache in patients presenting with cyclic vomiting syndrome and benign paroxysmal torticollis during infancy, and to define the main clinical features of the disorder. Methods We administered a questionnaire to the parents of all our pediatric patients with previous diagnosis of cyclic vomiting syndrome and/or benign paroxysmal torticollis according to ICHD-3; questions were focused on the main clinical features of the disorder as well as the prognosis, with particular emphasis on the development of headache. Results For the final analysis we considered 82 patients with cyclic vomiting syndrome and 33 with benign paroxysmal torticollis. Seventy-nine percent of patients with cyclic vomiting syndrome presented with headache during the follow-up, with a mean age at onset of 6 years; 67% of patients with benign paroxysmal torticollis suffered from headache during the follow-up, with a mean age at onset of 5 years. Discussion Cyclic vomiting syndrome and benign paroxysmal torticollis are associated with a very high risk of developing headache, mostly migraine, later in life. In both groups of patients, the vast majority presented with different episodic syndromes that may be associated with migraine at different ages, thus suggesting an age-dependent evolution of migraine-like symptoms before the onset of clear migrainous headache.

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Cyclic vomiting syndrome: a case series and review of the literature

Frontline Gastroenterology ◽

10.1136/flgastro-2016-100705 ◽

2016 ◽

Vol 9 (1) ◽

pp. 2-9 ◽

Cited By ~ 7

Author(s):

Jessica Shearer ◽

Pavit Luthra ◽

Alexander C Ford

Keyword(s):

Medical Records ◽

Tricyclic Antidepressants ◽

Case Series ◽

Response To Treatment ◽

Cyclic Vomiting Syndrome ◽

Review Of The Literature ◽

Duration Of Symptoms ◽

History Of ◽

Cannabis Smoking ◽

Cyclic Vomiting

ObjectiveCyclic vomiting syndrome (CVS) is under-recognised. Treatment is difficult as the pathophysiology is incompletely understood. We report our experience of treating patients with amitriptyline, and review the literature to summarise symptoms and associated features, epidemiology, potential pathophysiological mechanisms, differential diagnoses and treatment.DesignConsecutive adult patients with CVS were identified during a 5-year period from January 2010 until December 2015. Medical records were reviewed retrospectively, and age and sex of the patient, symptoms, associated features and response to treatment with amitriptyline were recorded.SettingA luminal gastroenterology clinic at a teaching hospital.ResultsSeventeen patients were identified (mean age 29.8 years, 13 (76.5%) female). Five had a history of cannabis use. Duration of symptoms prior to diagnosis ranged from 5 months to 15 years. Fourteen patients commenced amitriptyline, and in eight (57.1%) symptoms either ceased entirely or improved. Review of the literature suggested the prevalence of CVS was 0.5%. Symptoms are stereotypical, with acute episodes of nausea and vomiting, interspersed by periods when the patient is symptom-free. Proposed pathophysiologies include neuroendocrine dysfunction, mutations in mitochondrial DNA and re-intoxication effects from cannabis stored in fat tissues. Treatment during the acute phase is supportive, with rehydration, sedation and antiemetics. Prophylaxis to prevent future attacks with antihistamines, antimigraine drugs, antiepileptics and tricyclic antidepressants may be beneficial. Complete cessation of cannabis smoking should be advised.ConclusionsDiagnosis of CVS is often delayed in adults. Once identified, patients respond well to amitriptyline.

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Long Term Follow Up of Large Cohort of Adult Patients Receiving Tricyclic Antidepressants for Cyclic Vomiting Syndrome

The American Journal of Gastroenterology ◽

10.14309/00000434-201010001-01317 ◽

2010 ◽

Vol 105 ◽

pp. S485

Author(s):

Reza Hejazi ◽

Teri Lavenbarg ◽

Richard McCallum

Keyword(s):

Tricyclic Antidepressants ◽

Large Cohort ◽

Adult Patients ◽

Cyclic Vomiting Syndrome ◽

Long Term Follow Up ◽

Cyclic Vomiting

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Adult Cyclic Vomiting Syndrome Is Easy to Miss

Family Practice News ◽

10.1016/s0300-7073(07)70039-7 ◽

2007 ◽

Vol 37 (1) ◽

pp. 41

Author(s):

AMY ROTHMAN SCHONFELD

Keyword(s):

Cyclic Vomiting Syndrome ◽

Cyclic Vomiting

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Cannabinoid hyperemesis syndrome: definition, pathophysiology, clinical spectrum, insights into acute and long-term management

Journal of Investigative Medicine ◽

10.1136/jim-2020-001564 ◽

2020 ◽

Vol 68 (8) ◽

pp. 1309-1316

Author(s):

Mahesh Gajendran ◽

Joshua Sifuentes ◽

Mohammad Bashashati ◽

Richard McCallum

Keyword(s):

Symptom Control ◽

Well Being ◽

Clinical Entity ◽

Cyclic Vomiting Syndrome ◽

Cannabinoid Hyperemesis Syndrome ◽

Acute Attacks ◽

Hot Baths ◽

Term Management ◽

Cyclic Vomiting

Although cannabinoid hyperemesis syndrome (CHS) was first reported more than 15 years ago, it still remains an unfamiliar clinical entity among physicians worldwide. CHS is categorized by Rome IV classification as a functional gastroduodenal disorder. It is characterized by stereotypical episodic vomiting in the setting of chronic, daily cannabis use, with cycles decreasing by the cessation of cannabis. CHS is also associated with abdominal pain reduced by hot baths and showers with comparative well-being between attacks. Thus, its clinical presentation resembles ‘classic’ cyclic vomiting syndrome, but eliciting a cannabis history is crucial in diagnosing this entity. In acute attacks, parenteral benzodiazepines are very effective. For prevention and long-term management, tricyclic antidepressants such as amitriptyline are the mainstay of therapy requiring doses in the range of 50–200 mg/d to achieve symptom control. In addition, counseling to achieve marijuana cessation, accompanied by antianxiety medications, is necessary for sustaining clinical outcomes. Once the patient is in remission and off marijuana for a period of 6–12 months, then tapering the dose of amitriptyline can be implemented, with the goal of no therapy being achieved in the majority of patients over time. With the legalization of marijuana in many states, CHS will become an increasingly prevalent clinical entity, so educating about CHS is an important goal, particularly for emergency department physicians who generally first encounter these patients.

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CO17 FLUNARIZINE IN THE TREATMENT OF CYCLIC VOMITING SYNDROME (CVS)

Digestive and Liver Disease ◽

10.1016/s1590-8658(12)60645-8 ◽

2012 ◽

Vol 44 ◽

pp. S248

Author(s):

R. Mallamace ◽

D. Comito ◽

S. Cardile ◽

A. Chiaro ◽

C. Romano

Keyword(s):

Cyclic Vomiting Syndrome ◽

Cyclic Vomiting

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Efficacy of Coenzyme Q10 in the Treatment of Cyclic Vomiting Syndrome in Children

10.26420/jpediatrchildhealthcare.2021.1038 ◽

2021 ◽

Vol 6 (1) ◽

Author(s):

Brezin F ◽

◽

Wiedemann A ◽

Bansept C ◽

Albuisson E ◽

...

Keyword(s):

Coenzyme Q10 ◽

Gastrointestinal Disorder ◽

Cyclic Vomiting Syndrome ◽

Line Treatment ◽

First Line ◽

Excellent Safety Profile ◽

Third Line ◽

One Year ◽

First Line Treatment ◽

Cyclic Vomiting

Cyclic Vomiting Syndrome (CVS) is a chronic functional gastrointestinal disorder related to migraine, characterized by episodic nausea and vomiting. The treatment of CVS remains based on tricyclic antidepressants, triptans and antiepileptics. As mitochondriopathy has been involved in the pathophysiology of CVS, Coenzyme Q10 (CoQ10), a mitochondrial cofactor, has been used as the third line treatment in CVS. Considering the excellent safety profile of CoQ10, we decided to use it as the first line treatment in CVS. We retrospectively studied the evolution of 23 CVS patients who were treated for one year by CoQ10 alone. We recorded the characteristics of patients and their CVS history and compared data obtained the year before and the year following the prescription of CoQ10 treatment. We found a significant decrease in the number of vomiting episodes between the year before and the year after the start of CoQ10 (median [IQR]: 18.0 [15.75] vs. 3.00 [5.0]; p <0.001). This decrease persisted with time (2 and 3 years of treatment). The treatment was very efficient in 17/23 patients and did not decrease the number of vomiting episodes in 3 patients. Only one mild side effect related to the drug has been reported. Conclusions: CoQ10 is an efficient and safe treatment of CVS and should be used as the first line treatment in this episodic syndrome related to migraine.

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