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Prevention and Treatment of Motion Sickness ANDREW BRAINARD, MD, MPH, and CHIP GRESHAM, MD, Middlemore Hospital, Auckland, New Zealand

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Prevention and Treatment of Motion Sickness ANDREW BRAINARD, MD, MPH, and CHIP GRESHAM, MD, Middlemore Hospital, Auckland, New Zealand Prevention and Treatment of Motion Sickness ANDREW BRAINARD, MD, MPH, and CHIP GRESHAM, MD, Middlemore Hospital, Auckland, New Zealand Motion sickness is a common syndrome that occurs upon exposure to certain types of motion. It is thought to be caused by conflict between the vestibular, visual, and other proprioceptive systems. Although nausea is the hallmark symptom, it is often preceded by stomach awareness, malaise, drowsiness, and irritability. Early self-diagnosis should be emphasized, and patients should be counseled about behavioral and pharmacologic strategies to prevent motion sick- ness before traveling. Patients should learn to identify situations that will lead to motion sick- ness and minimize the amount of unpleasant motion they are exposed to by avoiding difficult conditions while traveling or by positioning themselves in the most stable part of the vehicle. Slow, intermittent exposure to the motion can reduce symptoms. Other behavioral strategies include watching the true visual horizon, steering the vehicle, tilting their head into turns, or lying down with their eyes closed. Patients should also attempt to reduce other sources of physi- cal, mental, and emotional discomfort. Scopolamine is a first-line medication for prevention of motion sickness and should be administered transdermally several hours before the antici- pated motion exposure. First-generation antihistamines, although sedating, are also effective. Nonsedating antihistamines, ondansetron, and ginger root are not effective in the prevention and treatment of motion sickness. (Am Fam Physician. 2014;90(1):41-46. Copyright © 2014 American Academy of Family Physicians.) CME This clinical content otion sickness is a syndrome Rotary, vertical, and low-frequency motions conforms to AAFP criteria that occurs when a patient is produce more symptoms than linear, hori- for continuing medical exposed to certain types of zontal, and high-frequency motions.1 education (CME). See CME Quiz Questions on motion and usually resolves page 16. Msoon after its cessation. It is a common Clinical Presentation Author disclosure: No rel- response to motion stimuli during travel. Although nausea may be the first recognized evant financial affiliations. Although nausea is a hallmark symptom, the symptom of motion sickness, it is almost ▲ syndrome includes symptoms ranging from always preceded by other subtle symptoms Patient information: A handout on this topic, vague malaise to completely incapacitating such as stomach awareness (i.e., a sensation of written by the authors of illness. These symptoms, which can affect fullness in the epigastrium), malaise, drowsi- this article, is available the patient’s recreation, employment, and ness, and irritability. Failure to attribute early at http://www.aafp.org/ afp/2014/0701/p41-s1. personal safety, can occur within minutes of symptoms to motion sickness may lead to html. experiencing motion and can last for several delays in diagnosis and treatment. Although hours after its cessation. mild symptoms are common, severely debili- Nearly all persons will have symptoms tating symptoms are rare 2 (Table 11,2). in response to severe motion stimuli, and a history of motion sickness best predicts Behavioral Interventions future symptoms.1 Females, children two Prevention of motion sickness is more effec- to 15 years of age, and persons with condi- tive than treating symptoms after they have tions associated with nausea (e.g., early preg- occurred. Therefore, patients should learn to nancy, migraines, vestibular syndromes) identify situations that may lead to motion report increased susceptibility. sickness and be able to initiate behavioral strategies to prevent or minimize symp- Etiology toms1,2 (Table 21-13). The pathogenesis of motion sickness is not clearly understood, but it is thought to be MINIMIZE VESTIBULAR MOTION related to conflict between the vestibular, Patients should be advised to avoid traveling visual, and other proprioceptive systems.2 in difficult weather conditions. If they must JulyDownloaded 1, 2014 from◆ Volume the American 90, Number Family Physician 1 website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2014 American Academy of FamilyAmerican Physicians. Family For the private,Physician noncom 41- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Motion Sickness travel, they should sit in the part of the vehi- SORT: KEY RECOMMENDATIONS FOR PRACTICE cle with the least amount of rotational and 2 Evidence vertical motion. This is usually the lowest Clinical recommendation rating References level in trains and buses, close to water level and in the center of boats, and over the wing To prevent and reduce symptoms of motion C 2-5 sickness, passengers should look forward at on airplanes. a fixed point on the horizon and avoid close visual tasks. HABITUATE TO MOTION To prevent and reduce symptoms of motion C 6-8 With continuous exposure to motion, symp- sickness in vehicles, passengers should toms of motion sickness will usually subside actively steer, tilt their head into turns, recline, stabilize their head and body, or rest with in one to two days. Alternatively, slow, inter- their eyes closed. mittent habituation to motion is an effective Scopolamine should be a first-line medication A 1, 2, 14, 15, strategy to reduce symptoms.1 For example, for preventing motion sickness in persons who 20, 21, 24 spending the first night aboard a boat in the wish to maintain wakefulness during travel. marina, followed by a day acclimating in the First-generation antihistamines are effective for B 1, 2, 16, 17, preventing motion sickness, but often have 19-21, 26 harbor, is preferable to going straight into sedative and other side effects. the open ocean. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited- SYNCHRONIZE THE VISUAL SYSTEM WITH quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual THE MOTION practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort. A small study found that focusing on the true horizon (skyline) minimized symp- toms of motion sickness.5 A survey of 3,256 bus passengers suggested that forward vision was helpful in reducing symptoms.3 Another Table 1. Signs and Symptoms of Motion Sickness study indicated that forward vision in a car can reduce symptoms.4 Severity Signs Symptoms Mild Belching Stomach awareness ACTIVELY SYNCHRONIZE THE BODY WITH THE MOTION Yawning Malaise Facial and perioral pallor Headache Actively steering the vehicle is an accepted Heartburn Irritability strategy for reducing symptoms of motion Hypersalivation Drowsiness sickness, although evidence is limited.7 Addi- Urinary frequency Fatigue tionally, a small study of automobile passen- Moderate Cold diaphoresis Nausea gers found that actively tilting the head into 6 Flushing Nonvertiginous dizziness turns was effective in preventing symptoms. Increased body warmth Apathy A survey of 260 cruise ship passengers sup- Hyperventilation Depression ported the common advice to recline and Vomiting Disinterest in social activities passively stabilize themselves if they are Disinclination for work unable to initiate active movements.8 Decreased cognitive performance Exaggerated sense of motion REDUCE OTHER SOURCES OF PHYSICAL, Increased postural sway MENTAL, AND EMOTIONAL DISCOMFORT Severe Inability to walk Social isolation Frequent consumption of light, soft, bland, Incapacitation low-fat, and low-acid food can minimize 2 Loss of postural stability symptoms of motion sickness. Treating 2 Persistent retching gastritis is useful, as is avoiding nausea- inducing stimuli (e.g., alcohol, noxious NOTE: Signs and symptoms are listed in decreasing order of prevalence. odors). Discussing symptoms with others Information from references 1 and 2. can exacerbate the condition. Passengers should be well rested, well hydrated, well fed, 42 American Family Physician www.aafp.org/afp Volume 90, Number 1 ◆ July 1, 2014 Motion Sickness Table 2. Behavioral Strategies to Prevent or Minimize Symptoms of Motion Sickness General principle Tactics General principle Tactics Minimize Avoid particularly noxious types of motions Actively Perform active movements if vestibular Complex (multiple and off-axis) motions are worse synchronize the possible motion than simple (one-axis) motions body with the Actively tilt head into turns6 motion Low-frequency motions are worse than high- Pilot the vehicle or connect with frequency motions steering device 7 Rotary motion is worse than linear motion Stand with legs bent, and anticipate Vertical motions are worse than horizontal motions the motion by moving entire body Avoid travel in difficult conditions and Actively swim if in water locations Walk around the vehicle if possible Avoid air travel in storms and turbulent conditions If unable to perform active Avoid terrain with many turns, accelerations, and movements ups and downs Brace body and head to avoid Avoid travel on water in storms and large waves additional motion8 Avoid travel through fog, clouds, and other Lay supine or recline head to conditions with poor visibility 30 degrees Choose location within the vehicle that Reduce other Treat and prevent gastritis2 minimizes motion sources of Avoid alcoholic drinks physical, Airplanes: over the wing Eat before traveling, and avoid an mental, and Automobiles: driver’s or front
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