By Sumit Parikh, M.D.
Co-Director of the Cleveland Clinic Neurogenetics/Neurometabolism Clinic and the Cyclic Vomiting Syndrome Center, Neuroscience Institute, Cleveland Clinic, Cleveland, Ohio
Q. My child has headaches that occur every month. They’re mild, but he also vomits frequently and intensely for several hours. Are these migraines or something else?
A. It sounds like your child may have cyclic vomiting syndrome (CVS), a frustrating and challenging, but not life-threatening, condition that is a migraine variant. CVS is characterized by explosive, recurrent, prolonged and severe attacks of vomiting with no other underlying cause.
This condition typically begins in a preschool- or elementary school-age child who is otherwise completely well. The episodes of vomiting start abruptly at any time of the day, though most commonly early in the morning. Vomiting occurs many times an hour, often every 10 minutes, gradually slowing down in intensity over a period of hours to days. The vomiting resolves on its own and almost instantaneously.
During the spell, children are described as appearing pale and are sensitive to noise and light. They often want to be left completely alone in a dark room. They may also complain of a headache and a stomachache, though it is the vomiting that is the most troubling symptom. Their bowel movements may become loose or they may have actual diarrhea. They appear sleepy during and after the vomiting. Due to the frequent vomiting, a child may quickly empty his or her stomach and then vomit bile, which is a green color. Infrequently, a child may have blood in his or her vomit, which is usually from irritation of the esophagus from frequent vomiting.
The bouts of vomiting can recur weekly or monthly and the spell is often predictable to the day and, at times, the hour of onset. The episodes of vomiting can be triggered by stress (tests, divorce, homework), excitement (vacations, birthdays), motion sickness, certain foods and viral illness. In between, the child appears completely well.
There is often a family history of migraines and many CVS patients transition to having migraines themselves when they get older.
This condition is still frequently misdiagnosed, which means its true incidence is still not known. Unfortunately, there is no single test or procedure to help make the diagnosis. The stomach flu or food poisoning are often diagnosed with the initial bout of vomiting until the spells recur. Despite increasing awareness of this condition, diagnosis is typically delayed two to three years after onset of symptoms. The diagnosis is made after careful review of the patient’s history, along with the exclusion of other causes of vomiting such as neurologic and gastrointestinal problems.
Once a diagnosis is made, treatment includes anti-vomiting and migraine medications during the bouts of vomiting and, if the spells are frequent, a medication to help prevent them. In case the vomiting is very severe or lasts days, intravenous fluids may need to be given to prevent dehydration. We have also started looking at non-traditional treatment options, such as certain vitamins and stress management therapy, to help prevent these spells.
The diagnosis, evaluation and treatment of CVS are typically coordinated by a gastroenterologist and neurologist. More recently, metabolic specialists have become involved in the evaluation. Certain medical centers have created CVS diagnosis and treatment specialty clinics.
A protocol for appropriate diagnosis and management has been developed by the National CVS Association Medical Advisory Board and is available through their Web site, www.cvsaonline.org.