Migraine and Cyclic Vomiting Syndrome

Medically reviewed by: B U.K. Li, MD

What is Cyclic Vomiting Syndrome?

Cyclic vomiting syndrome (CVS) is a condition characterized by repeated episodes of severe nausea and vomiting without a known cause.¹ It occurs in 2% of both children and adults.² Most individuals also experience severe abdominal pain. Episodes can last from a few hours to seven days (most commonly, 1-4 days) and can occur several times a month or a few times per year.¹ Between episodes, individuals experience other chronic symptoms like anxiety and daily nausea. The key features are recurrent attacks of vomiting when no one else in the household is ill, with each attack resembling the others in timing, duration, and symptoms (vomiting, nausea, abdominal pain, paleness, listlessness).

Episodes of CVS often follow a similar pattern:³

• Prodrome phase: Before the vomiting starts, intense nausea, abdominal pain, and sweating occur. This is often noticed in the early morning hours before an attack.
• Vomiting phase:¹ Repeated vomiting and retching occur, sometimes as often as every 10 minutes. This phase can be so intense that it causes paleness, extreme thirst, and an inability to speak or move. Some individuals also experience diarrhea, headache, dizziness, loss of appetite, or a low-grade fever. People with CVS can develop dehydration and require an IV for fluids. The fever and diarrhea often lead to a mistaken diagnosis of stomach flu (gastroenteritis). 
• Recovery phase: Vomiting and retching stop, nausea lessens, and other symptoms fade.
• Well/inter-episodic phase: There is a return to baseline health, although some people may still experience some symptoms.⁴ A person’s healthy skin color, appetite, and energy return until the next episode.

CVS can begin at any age and persist for months, years, or decades. Although it was originally reported to be a childhood disorder, cyclic vomiting syndrome is now being recognized at an increasing rate in adults.⁵

Causes and Diagnosis of Cyclic Vomiting Syndrome

Possible causes of CVS include:⁶

• Problems with communication between the brain and the gut
• Changes in how the nervous system and hormones respond to stress
• Mutations in certain (mitochondrial) genes that provide energy

In many cases, the exact cause of cyclic vomiting syndrome is still unknown.

However, many people can identify triggers that bring on an episode.⁷ Common triggers include colds or other infections, physical exhaustion or lack of sleep, hormonal changes or menstruation, certain foods, and emotional stress or excitement.⁷

CVS may be considered mild when an individual experiences fewer than 4 episodes per year, each lasting less than 2 days, without emergency room visits or hospitalizations.⁸ Or it may be moderate to severe, with 4 or more episodes per year, each lasting over 2 days, and requiring at least one emergency room visit or hospitalization.⁸ 

CVS can be difficult to diagnose because vomiting is a symptom of many conditions. To help clinicians recognize cyclic vomiting syndrome, experts developed a set of guidelines known as the Rome V Criteria.⁹ Diagnosis involves a careful review of the patient’s history and a physical exam, along with limited testing to rule out other conditions.⁸

What is the Relationship Between Cyclic Vomiting Syndrome and Migraine?

CVS and migraine are closely linked.

Up to 80% of children with CVS either have a diagnosis of migraine or a family history of it.¹⁰ Adults with CVS have been studied less, but one study found that more than 70% experience migraine attacks, and many have a relative with migraine.¹¹

Because this link is so strong, a personal or family history of migraine can support the diagnosis of CVS.⁸ Some experts even consider CVS “migraine of the stomach.”⁸

Migraine and CVS also share many clinical features. Symptoms such as nausea, fatigue, and aura can occur with both conditions. They may share common triggers, including a lack of sleep, and commonly occur alongside comorbid conditions such as anxiety and depression. Although most children outgrow CVS during adolescence, an estimated 75% of children will develop migraine as adults.¹²

Finally, CVS and migraine often respond to similar preventive and acute therapies. If the individual has both, the same treatment can treat both the CVS and migraine.¹³

Commonalities Between Cyclic Vomiting Syndrome and Migraine

• Both CVS and migraine are more common in females.¹⁴
• Attacks are episodic, typically with symptom-free periods between.
• Sensitivity to light (photophobia) and sound (phonophobia) can occur during migraine and vomiting attacks. Resting in a dark, quiet room often helps. 
• Some individuals can identify triggers before an attack, such as stress, illness, or certain foods, while others cannot.
• Both conditions often progress through phases.
• There is no single test or scan that can definitively diagnose either condition. The diagnosis is based on symptoms and a clinical exam. 
• There is no cure for either condition.
• Symptoms of migraine, abdominal migraine, and cyclic vomiting syndrome (CVS) overlap. CVS is usually diagnosed when vomiting is the main symptom.¹⁰ If abdominal pain (usually very severe) is the primary symptom, it may be diagnosed as abdominal migraine.¹⁰ When headache is the most troublesome symptom, migraine is likely.¹⁰
• Some patients of both conditions report symptom relief with low-dose cannabis use, but more research is needed to understand its safety and effectiveness.^5,14,15
• CVS and migraine evolve with age, and some individuals experience fewer symptoms or even “outgrow” their condition.

Treatments for Cyclic Vomiting Syndrome and Migraine

Treatment for CVS, like migraine treatment, uses a combination of lifestyle changes, psychotherapy, devices, and medications.¹³ These include:

• Lifestyle changes: Identify and avoid triggers, and establish healthy daily routines that include good sleep habits, a balanced diet, and stress-management techniques. 
• Preventive and acute medications: Medications to prevent and/or stop CVS symptoms can be used just like treatment for migraine. See below for more information.
• Psychotherapy: Anxiety, panic attacks, and other psychiatric conditions are common in people with CVS and migraine.¹⁶ Guidelines from the Cyclic Vomiting Syndrome Association (CVSA) and the American Neurogastroenterology and Motility Society recommend that clinicians screen for and treat these conditions to improve patients’ quality of life and decrease healthcare costs.¹³

Although there is currently no cure for CVS or migraine, both conditions can often be well managed with acute and preventive treatments.

Preventive Treatments

The goal of preventive therapy is to prevent attacks from occurring. Currently, preventive medications are only recommended for people with moderate-to-severe CVS (>4 episodes/year, each lasting >2 days, and associated with visits to the ED/hospital).⁸ Preventive treatment is generally considered for people with migraine who experience 4 or more headache days per month.¹⁷

Amitriptyline and other antidepressants in its class are prevention options for both CVS and migraine. Across various studies, about 70% of people with CVS reported improvement with this medication class.¹³ Interestingly, some research suggests that people with a history of migraine may be less likely to respond to this medication.⁵

Anti-seizure medications, such as topiramate, can also be used to prevent CVS episodes.¹³ They are also used to prevent migraine attacks.¹³ However, these medications are often prescribed with caution in women of childbearing age.

Other options that may be used in people with migraine and/or CVS include propranolol, a beta-blocker, and cyproheptadine, an antihistamine, as well as vitamins and supplements such as coenzyme Q10 and riboflavin. In addition to coenzyme Q10 and riboflavin, magnesium is often recommended for the preventive treatment of migraine.¹³

Vagal stimulation (by ear), although not widely available, shows promise for CVS. Vagal stimulation of the neck is FDA-cleared for acute and/or preventive migraine treatment in people aged 12 and older.¹⁸

Aprepitant may be used as preventive treatment for people with CVS or as an acute treatment.¹³

Acute Medications

The goal of acute therapy is to stop or ease symptoms as soon as an episode or attack begins. Unlike preventive treatment, all patients with CVS and migraine should receive an acute medication.

Short-term use of NSAIDs (like ibuprofen, naproxen, or ketorolac) can provide relief for abdominal or head pain.

Triptans, such as sumatriptan, can halt symptoms in both CVS and migraine. Ideally, individuals with CVS should take a triptan within an hour after the prodrome (warning signs) develop, even before the vomiting begins.¹³ Nasal sprays or injections are preferred over oral options. Sumatriptan is often used in combination with an anti-nausea medication, like ondansetron, in CVS and migraine. 

Aprepitant is often a safe alternative. 

During the recovery phase of CVS, the priority is to consume electrolyte beverages or other nutrient-rich drinks and to get adequate rest. The recovery phase typically lasts 1-2 days.⁸

For more information about migraine treatments, click here.

What Type of Clinician Should I See for Cyclic Vomiting Syndrome and Migraine?

A primary care provider (PCP) is usually the best first contact for patients with suspected migraine or cyclic vomiting syndrome. A PCP can perform an initial evaluation, rule out other causes, and coordinate care with other specialists if needed.

Migraine is best managed by a clinician with expertise in headache medicine, often a neurologist.

For CVS, consistent care from a provider who understands the condition is key. Pediatric or adult gastroenterologists often help manage CVS, but nonspecialists–including PCPs and emergency medicine clinicians–can also diagnose and care for it. 

Patients seeking specialized expertise in CVS can submit a request for a physician near them through the Cyclic Vomiting Syndrome Association’s (CVSA) website here.

A Note to Patients and Providers

Healthcare providers should be aware of the connection between cyclic vomiting syndrome and migraine. 

Both conditions are complex, rely on symptom-based screening tools for diagnosis, and don’t have a single definitive test or marker.

If you have migraine, it’s important to tell your healthcare provider if you notice:

• Episodes of repetitive vomiting
• Periods of unrelenting nausea and retching
• Bouts of severe abdominal pain

Providing these details can help your clinician recognize when both conditions may be present.

When both CVS and migraine are diagnosed, individuals may benefit from treatments that address both disorders, such as NSAIDS and/or sumatriptan, propranolol, cyproheptadine, amitriptyline, or topiramate.

Understanding the connection between CVS and migraine can help individuals with the conditions and providers work together to manage symptoms more effectively and improve daily life.

Allied Partner Resources

• Submit a request to find a nearby provider
• New Patient information
• E-Newsletter Sign-up
• Online support options
• Support Call sign-up
• Resources for School
• “Episodes” Podcast by CVSA
• More resources

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View the podcast between CVSA and AMD:

References

1. https://www.cvsaonline.org/what-is-cvs/
2. https://emedicine.medscape.com/article/933135-overview
3. https://my.clevelandclinic.org/health/diseases/14894-cyclic-vomiting-syndrome
4. https://onlinelibrary.wiley.com/doi/10.1002/jpn3.12448
5. https://pmc.ncbi.nlm.nih.gov/articles/PMC7309299/
6. https://www.niddk.nih.gov/health-information/digestive-diseases/cyclic-vomiting-syndrome/symptoms-causes
7. https://badgut.org/information-centre/a-z-digestive-topics/cyclic-vomiting-syndrome/
8. https://www.gastrojournal.org/article/S0016-5085(24)05025-X/fulltext
9. https://pubmed.ncbi.nlm.nih.gov/41713704/
10. https://www.cvsaonline.org/for-health-providers/treatment-guidelines/#1753914652070-ac07451b-74ee
11. https://link.springer.com/article/10.1186/1741-7015-3-20
12. https://pmc.ncbi.nlm.nih.gov/articles/PMC11911070/
13. https://pmc.ncbi.nlm.nih.gov/articles/PMC6899751/
14. https://www.cghjournal.org/article/S1542-3565(18)30552-4/pdf
15. https://pmc.ncbi.nlm.nih.gov/articles/PMC9845509/
16. https://pmc.ncbi.nlm.nih.gov/articles/PMC1326207/
17. https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/head.14153
18. https://www.gammacore.com/about-gammacore/how-gammacore-works/

Author

Nicholas earned his B.S. in Biology with Honors Distinction in Neurobiology from Stanford University. After graduating, he spent a year conducting behavioral neuroscience research at the National Institutes of Health. He then returned to his roots in Rhode Island to pursue his M.D. at The Warren Alpert Medical School of Brown University. To date, Nicholas has received over $50,000 in funding for his basic science and clinical research at Stanford, Brown, Massachusetts General Hospital, and the NIH. He also mentors undergraduate and junior medical students, volunteers at a free clinic, and supports advocacy efforts at both the state and national levels. In his free time, Nicholas enjoys traveling, spending quality time with loved ones, and exploring Rhode Island’s fantastic food scene. He is excited to bring his talents and experience to the Association of Migraine Disorders.

*The contents of this blog are intended for general informational purposes only and do not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. The writer does not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.