Can you recognize cyclic vomiting syndrome?

Cyclic vomiting syndrome (CVS), a variant of migraine, was first described in the literature over a century ago, but in 2015, it remains commonly unrecognized and misdiagnosed.

Because CVS causes significant morbidity, pediatricians need to know its characteristic signs and symptoms and include CVS in their differential diagnosis in any child with repeated bouts of “stomach flu” or “gastroenteritis”, said B.U.K. Li, MD, Professor of Pediatrics (Gastroenterology), Medical College of Wisconsin, Milwaukee.

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In a session on Tuesday, October 27, Dr Li familiarized attendees with the clinical features of CVS and described its diagnosis and management.

“Children with CVS typically present to emergency departments [EDs] and pediatrician offices with rapid fire vomiting often resulting in dehydration,” said Dr Li. “Despite a history of having similar episodes within the past several months, they are mislabeled as having a virus, gastroenteritis, or food poisoning. In our studies we found time to proper diagnosis was delayed by an average of 30 months and occurred after an average of 10 ED visits.”

“In the meantime, these children may undergo a lot of unnecessary testing and face burdens of missed school, missed work for the parents, and decreased health-related quality of life.”
Maintaining an index of suspicion for CVS is the first step to a timely diagnosis. The disorder should be considered in a child who has more than 3 bouts of severe vomiting within a period of 6 to 12 months in which the vomiting occurs with high frequency (every 10-15 minutes initially) without any identifiable cause. Often, these discrete episodes occur in conjunction with a positive stressor (eg, birthdays, holidays, vacations) and awaken the child in the early morning hours. A family history of migraine is another clue for diagnosing CVS.

The initial screening work-up for children who meet these criteria without red flags such as bilious vomiting, typical metabolic triggers (fasting, high protein meal), and abnormal neurological exam, is minimal, with the main test being an upper gastrointestinal x-ray to exclude malrotation.

If no abnormality is found on imaging, children may be started on prophylactic anti-migraine medications, using cyproheptadine in children aged under 5 years and amitriptyline for older children and adolescents.

Dr Li also noted there is accumulating evidence that children with CVS commonly have other chronic health issues, including anxiety, irritable bowel syndrome/constipation, limited stamina on aerobic exercise, disordered sleep, and postural orthostatic tachycardia syndrome. These comorbidities can further compromise the quality of life issues experienced by children with CVS and should be addressed separately from the treatment for CVS.