Cyclic Syndrome

What is cyclic vomiting wake up in the morning and begin syndrome (CVS)? vomiting.  Vomiting phase. This phase consists of CVS is characterized by episodes or cycles of and vomiting; an inability to eat, severe nausea and vomiting that last for hours, or drink, or take medicines without vomiting; even days, that alternate with intervals with no paleness; drowsiness; and exhaustion. symptoms. Although originally thought to be a  Recovery phase. This phase begins when pediatric disease, CVS occurs in all age groups. the nausea and vomiting stop. Healthy Medical researchers believe CVS and color, appetite, and energy return. are related (see “CVS and Migraine” on page 2). What triggers CVS? Each episode of CVS is similar to previous ones, Many people can identify a specific condition or meaning the episodes tend to start at the same time event that triggered an episode, such as an of day, last the same length of time, and occur with . Common triggers in children include the same symptoms and level of intensity. emotional and excitement. Anxiety and Although CVS can begin at any age, in children it panic attacks are more common triggers in adults. starts most often between the ages of 3 and 7. Colds, allergies, sinus problems, and the flu can Episodes can be so severe that a person has to stay also set off episodes in some people. in bed for days, unable to go to school or work. The exact number of people with CVS is Other reported triggers include eating certain foods unknown, but medical researchers believe more such as chocolate or cheese, eating too much, or people may have the disorder than commonly eating just before going to bed. Hot weather, thought. Because other more common diseases and physical exhaustion, menstruation, and motion disorders also cause cycles of vomiting, many sickness can also trigger episodes. people with CVS are initially misdiagnosed until other disorders can be ruled out. CVS can be disruptive and frightening not just to people who What are the symptoms have it but to family members as well. of CVS?

A person who experiences the following The Four Phases of CVS symptoms for at least 3 months—with first CVS has four phases: onset at least 6 months prior—may have CVS:  Symptom-free interval phase. This  vomiting episodes that start with severe phase is the period between episodes vomiting—several times per hour—and when no symptoms are present. last less than 1 week  phase. This phase signals that  three or more separate episodes of an episode of nausea and vomiting is vomiting in the past year about to begin. Often marked by nausea—  absence of nausea or vomiting between with or without abdominal pain—this episodes phase can last from just a few minutes to several hours. Sometimes, taking A person with CVS may experience abdominal medicine early in the phase can stop an pain, , fever, dizziness, and sensitivity to episode in progress. However, sometimes light during vomiting episodes. Continued there is no warning; a person may simply vomiting may cause severe dehydration that can be life threatening. Symptoms of dehydration include Once a vomiting episode begins, treatment usually thirst, decreased urination, paleness, exhaustion, requires the person to stay in bed and sleep in a and listlessness. A person with any symptoms of dark, quiet room. Severe nausea and vomiting may dehydration should see a health care provider require hospitalization and intravenous fluids to immediately. prevent dehydration. Sedatives may help if the nausea continues. How is CVS diagnosed? Sometimes, during the prodrome phase, it is CVS is hard to diagnose because no tests— such possible to stop an episode from happening. For as a blood test or x ray—can establish a diagnosis example, people with nausea or abdominal pain of CVS. A doctor must look at symptoms and before an episode can ask their doctor about taking medical history to rule out other common diseases (Zofran) or (Ativan) for or disorders that can cause nausea and vomiting. nausea or ibuprofen (Advil, Motrin) for pain. Making a diagnosis takes time because the doctor Other medications that may be helpful are also needs to identify a pattern or cycle to the ranitidine (Zantac) or omeprazole (Prilosec), which vomiting. help calm the stomach by lowering the amount of

acid it makes. CVS and Migraine During the recovery phase, drinking water and The relationship between migraine and CVS is replacing lost electrolytes are important. still unclear, but medical researchers believe the Electrolytes are salts the body needs to function two are related. and stay healthy. Symptoms during the recovery phase can vary. Some people find their appetite  Migraine headaches, which cause severe returns to normal immediately, while others need head pain; abdominal , which to begin by drinking clear liquids and then move cause stomach pain; and CVS are all slowly to solid food. marked by severe symptoms that start and end quickly and are followed by intervals People whose episodes are frequent and long- without pain or other symptoms. lasting may be treated during the symptom-free  Many of the situations that trigger CVS intervals in an effort to prevent or ease future also trigger migraines, including stress episodes. Medications that help people with and excitement. migraine headaches, such as propranolol  Research has shown that many children (Inderal), cyproheptadine (Periactin), and with CVS either have a family history of (Elavil), are sometimes used migraine or develop migraines as they during this phase, but they do not work for grow older. everyone. Taking the medicine daily for 1 to 2 months may be necessary before one can tell if it Because of the similarities between migraine and helps. CVS, doctors treat some people with severe CVS with drugs that are also used for migraine The symptom-free interval phase is a good time headaches. The drugs are designed to prevent to eliminate anything known to trigger an episodes, reduce frequency, and lessen severity. episode. For example, if episodes are brought on by stress or excitement, a symptom-free interval How is CVS treated? phase is the time to find ways to reduce stress Treatment varies, but people with CVS generally and stay calm. If sinus problems or allergies improve after learning to control their symptoms. cause episodes, those conditions should be People with CVS are advised to get plenty of rest treated. and sleep and to take medications that prevent a During an episode, anti-migraine drugs such as vomiting episode, stop one in progress, speed up sumatriptan (Imitrex) may be prescribed to stop recovery, or relieve associated symptoms. symptoms of migraine . However, these agents have not been studied for use in children.

What are the complications of  The only way a doctor can diagnose CVS is by looking at symptoms and medical CVS? history to rule out any other possible The severe vomiting that defines CVS is a risk causes for the nausea and vomiting. Then factor for several complications: the doctor must identify a pattern or cycle to the symptoms.  Dehydration. Vomiting causes the body to lose water quickly. Dehydration can be  Treatment varies by person, but people severe and should be treated immediately. with CVS generally improve after learning to control their symptoms. They may also  Electrolyte imbalance. Vomiting causes be given medications that prevent a the body to lose important salts it needs to vomiting episode, stop one in progress, keep working properly. speed up recovery, or relieve associated  Peptic . The — the symptoms. tube that connects the mouth to the  Complications include dehydration, which stomach—becomes injured from stomach can be severe; electrolyte imbalance; acid moving through it while vomiting. peptic esophagitis; ; Mallory-  Hematemesis. The esophagus becomes Weiss tear; and . irritated and bleeds, so blood mixes with vomit.  Mallory-Weiss tear. The lower end of the Hope through Research esophagus may tear open or the stomach The National Institute of Diabetes and Digestive may bruise from vomiting or retching. and Kidney Diseases’ Division of Digestive Diseases and Nutrition supports basic and clinical  Tooth decay. The acid in vomit can hurt research into functional gastrointestinal disorders, teeth by corroding tooth enamel. including cyclic vomiting syndrome. More research is needed in the areas of diagnosis and treatment of this condition. Points to Remember  People with CVS have severe nausea and Participants in clinical trials can play a more active vomiting that come in cycles. role in their own health care, gain access to new research treatments before they are widely  CVS occurs in all age groups. available, and help others by contributing to  Medical researchers believe CVS and medical research. For information about current migraine headaches are related. studies, visit www.ClinicalTrials.gov.

 CVS has four phases: symptom-free This publication is not copyrighted. The interval phase, prodrome phase, vomiting Clearinghouse encourages users of this publication phase, and recovery phase. to duplicate and distribute as many copies as desired.  Many people can identify a condition or This publication is available at event that triggers an episode of nausea www.digestive.niddk.nih.gov. and vomiting. and emotional stress are two common triggers.  The main symptoms of CVS are episodes You may also find additional information about this topic by visiting MedlinePlus at www.medlineplus.gov. of nausea and vomiting that come and go. Vomiting can lead to severe dehydration This publication may contain information about medications. that can be life threatening. When prepared, this publication included the most current information available. For updates or for questions about any  Symptoms of dehydration include thirst, medications, contact the U.S. Food and Drug Administration toll-free at 1-888-INFO-FDA (1-888-463-6332) or visit decreased urination, paleness, exhaustion, www.fda.gov. Consult your health care provider for more and listlessness. A person with any information. symptoms of dehydration should see a health care provider immediately.