Table 7.
Medications available for pharmacological treatment of Cyclic Vomiting Syndrome (CVS) in children.
| Medications | Class | Mechanism of action | Goal and indication | Dose | Route of administration | Side effects |
|---|---|---|---|---|---|---|
| Sumatriptan | Antimigraine | 5HT1B/1D agonist | Prodromal phase as abortive therapy | 10 mg <40 Kg 20 mg > 40 kg (age × 4 + 20)/100 × 3 mg, in children 12 years and older |
Intranasal subcutaneous |
Neck pain/burning and coronary vasospasm and it is contraindicated in basilar artery migraine |
| Ondansetron | Antiemetic | 5-HT3 receptor antagonist | Abortive therapy | 0.3-−0.4 mg/kg/dose every 4–6 h, max 20 mg/day)0.15 mg/kg per dose recommended. | Intravenous oral/sublingual in patients with milder symptomatology | constipation, dry mouth, headache, drowsiness, QT prolongation |
| Cyproheptadine | Antimigraine | Anti-histamine, serotonin (5HT2) and calcium channel antagonist | Preventative First choice in children ≤ 5 years |
0.25–0.5 mg/kg/day Single night-time dose or divided bid or tid. |
Oral | Increased appetite, weight gain and sedation |
| Pizotifen | Antimigraine | Serotonin (5HT2) antagonist and anti-histamine |
Preventative alternative to cyproheptadine Available only in Canada and the UK |
0.5–1.5 mg at night | Oral | increased appetite, weight gain and sedation |
| Propranolol | Antimigraine | β-blockers | Preventative | 0.25–1 mg/kg/day, most often 10 mg bid or tid | Oral | lethargy, reduced exercise tolerance, bradycardia |
| Erythromycin | Antiemetic | Prokinetic agent | Preventative | 20 mg/Kg/day | Oral | |
| Aprepitant | Antiemetic | Neurokinin (NK1) receptor antagonist |
Preventative Phase as abortive therapy |
40 mg orally twice/week in children < 40 kg, 80 mg in children 40–60 kg, and 125 mg in children > 60 kg 125 mg 30 min before the emetic phase, followed 80 mg/day 2–3 >20 kg, 80 mg for 3 days 15- 20 kg, 80 mg/day 40 mg day 2–3 <15 kg. |
Oral | hiccups, fatigue, increased appetite, mild headache and severe migraine |
| Amitriptyline | Antidepressant | Tricyclic antidepressant | Preventative | Starting dose should be 0.2–0.3 mg/kg/day and increases of 5–10 mg/week should be done up to the highest dose of 1–1.5 mg/kg/day | Oral | Dry mouth, constipation, weight gain, morning tiredness, behavioral changes, cardiotoxicity (tachyarrhythmia) |
| Phenobarbital Valproic acid Topiramate |
Anticonvulsants | Barbiturate either multiple mechanism of action | Preventative | 2–3 mg/kg/day at bedtime 10–40 mg/kg/day 2 mg/kg/day divided in 2 daily doses |
Oral | Sedation, cognitive impairment, Hyperactivity, disruptive behavior Irritability, Anorexia/weight loss, Hypertermia/dehydratation |
| Flunarizine | Antimigraine | Non-selective calcium channel blocker | Preventative | 5 mg per day | Oral | Hypotension, Weight gain and appetite |
| Fluoxetine | Antidepressant | Selective serotonin reuptake inhibitor | Preventative | 20 mg/day as anxiolytic treatment (not enough evidence) | Oral | Gastrointestinal symptoms, Sleep changes, Headaches. Restless legs. Appetite changes |
| Carnitine | Mitochondrial supplements | Alternate preventive | 50–100 mg/kg/day, adults 1 g tid | Oral | Diarrhea, fishy body odor | |
| Co-enzyme Q10 | Mitochondrial supplements | Alternate preventive | 5–10 mg/kg/day, adults 100 mg tid | Oral | Diarrhea | |
| Riboflavin | Mitochondrial supplements | Alternate preventive | 400 mg daily or divided twice daily | Oral | Not described | |
| Ketorolac | Analgesic | Non-steroidal anti-inflammatory | Supportive | 0.4–1 mg/kg per dose every 6 h, max dose 30 mg, max daily dose 120 mg | Intravenous | gastrointestinal bleeding and dyspepsia |
| Omeprazole | Decreases stomach acid production | Proton pump inhibitors | Supportive | 0.1 mg/kg | Intravenous | |
| Lorazepam | Sedatives | 5-HT3 receptor antagonist | Supportive as rescue therapy | 0.05–0.1 mg/kg/dose iv every 6 h, max 4 mg. | Intravenous | Disorientation, dizziness, hypotension, respiratory depression |
| Chlorpromazine | Sedatives, antiemetic, antipsychotic | D2-antagonist | Supportive as rescue therapy | 0.5–1 mg/kg/dose every 6 h, max 40 mg/day <5 years; max 75 mg/day 5–12 years | Intravenous | Drowsiness, hypotension, seizure, extrapyramidal symptoms, arrhythmias |
| Diphenhydramine (only in association with chlorpromazine) | Sedatives, antiemetic, antihistamine | H1-antagonist | Supportive as rescue therapy | 1–1.25 mg/kg/dose every 6 h | Intravenous | Respiratory depression, hallucinations, hypotension, nausea, blurred vision |