Motion Sickness- Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

Not a true sickness, but a normal response to a situation in which sensory conflict about body motion exists among visual receptors, vestibular receptors, and body proprioceptorsAlso can be induced when patterns of motion differ from those previously experiencedSystem(s) affected: NervousSynonym(s): Car sickness; Sea sickness; Air sickness; Space sickness; Physiologic vertigo

Epidemiology

Incidence

Predominant sex: Female > Male

Risk Factors

Motion (auto, plane, boat, amusement rides)TravelVisual stimuli (e.g., moving horizon)Poor ventilation (fumes, smoke, carbon monoxide)Emotions (fear, anxiety)Zero gravityPregnancy, menstruation, oral contraceptive useHistory of migraine headachesOther illness or poor health

General Prevention

See General Measures.

Pediatric Considerations

Rare in children <2 years of ageIncidence peaks between the ages of 3 and 12 years.Antihistamines may cause excitation in children.

Geriatric Considerations

Age confers some resistance to motion sickness.Elderly at increased risk of anticholinergic side effects from treatment

Pregnancy Considerations

Pregnant patients more likely to experience motion sicknessTreat with medications thought to be safe during morning sickness (e.g., meclizine, dimenhydrinate).

Etiology

Precise etiology unknown; thought to be due to a mismatch of vestibular and visual sensationsNausea and vomiting occur as a result of increased levels of dopamine and acetylcholine, which stimulate chemoreceptor trigger zone and vomiting center in CNS.

Diagnosis

History

Presence of the following signs and symptoms:

NauseaVomitingDiaphoresisPallorHypersalivationYawningHyperventilationAnxietyPanicMalaiseFatigueWeaknessConfusionDizziness

Differential Diagnosis

Mountain sicknessVestibular diseaseGastroenteritisMetabolic disordersToxin exposure

Treatment

Follow guidelines under General Measures section to prevent motion sickness (1)[C].Premedicate before travel with antidopaminergic, anticholinergic, or antihistamine agents (1)[A]: For extended travel, consider treatment with scopolamine transdermal patch (2)[A].2nd-generation (nonsedating) antihistamines are not effective at preventing motion sickness (3)[B].Serotonin (5-HT3) antagonists (e.g., ondansetron) do not appear effective in preventing motion sickness (4)[B].Conflicting data exist on the efficacy of acupressure for nausea and vomiting associated with motion sickness (5)[B].Benzodiazepines suppress vestibular nuclei but would not be considered 1st line due to sedation and addiction potential (6)[C].

Medication

First Line

Scopolamine transdermal patch: Apply 2.5 cm2 (4-mg) patch behind ear at least 4 h (preferably 6–12 h) before travel, and replace every 3 days (2)[A]: Scopolamine may also be given in tablets, capsules, or oral solution; all are more effective than placebo (7)[A].Dimenhydrinate (Dramamine): Take 30 min–1 h before travel: Adults and adolescents: 50–100 mg q4–6h, maximum 400 mg/dChildren 6–12 years of age: 25–50 mg q6–8h, maximum 150 mg/dChildren 2–6 years of age: 12.5–25 mg q6–8h, maximum 75 mg/dMeclizine (Antivert): Take 30 min–1 h before travel. Adults and adolescents >12 years of age: 12.5–25 mg q12–24hCyclizine (Marezine): Take 30 min–1 h before travel: Adults and adolescents: 50 mg q4–6h, maximum 200 mg/dChildren 6–12 years of age: 25 mg up to t.i.d.Promethazine (Phenergan): Take 30 min–1 h before travel: Adults and adolescents: 25 mg q12h; 25–50 mg IM if already developed severe motion sicknessChildren 2–12 years of age: 0.5 mg/kg q12h, maximum 25 mg b.i.d. Caution: Increased risk of dystonic reaction in this age groupContraindications: Patients at risk for acute-angle closure glaucomaPrecautions: Young childrenElderlyPregnancyUrinary obstructionPyloric-duodenal obstructionAdverse reactions: DrowsinessDry mouthBlurred visionConfusionHeadacheUrinary retentionSignificant possible interactions: Sedatives (antihistamines, alcohol, antidepressants)Anticholinergics (belladonna alkaloids)

Second Line

Benzodiazepines: Take 1–2 h before travel: Diazepam 2–10 mg p.o. q6–12hLorazepam1–2 mg p.o. q8hContraindications: Severe respiratory dysfunctionSevere liver dysfunctionPrecautions: Alcohol/drug abuseElderlySedationAddiction is possible.

Additional Treatment

General Measures

Minimize exposure (sit in middle of plane or boat).Improve ventilation; avoid noxious stimuli.Semirecumbent seatingFix vision on horizon, avoid fixation on moving objects, keep eyes fixed on still, distant objects.Avoid reading while actively traveling.Minimize food intake before travel; avoid alcohol.Increase airflow around face.Acupressure on point PC6 has been shown to reduce feelings of nausea but not the incidence of vomiting during pregnancy, after surgery, and in cancer chemotherapy. However, conflicting evidence of efficacy has been found for motion sickness. Point PC6 (Neiguan on pericardium meridian): 2 cm proximal of transverse crease of palmar side of wrist between tendons of the palmaris longus and the flexor carpi radialis.

Complementary and Alternative Medicine

Ginger: 940 mg or 1 g; take 4 h before travel (evidence controversial)

Ongoing Care

Follow-Up Recommendations

Semirecumbent seatingAvoid reading while actively traveling.

Diet

Decrease oral intake or take frequent small feedings.Avoid alcohol.

Prognosis

Symptoms should resolve when motion exposure ends.Resistance to motion sickness seems to increase with age.

Complications

References

1. Committee to advise on tropical medicine and travel. Statement on motion sickness. CCDR. 2003;29:1–12.

2. Spinks A, Wasiak J, Bernath V, et al. Scopolamine (hyoscine) for preventing and treating motion sickness. CochraneDatabase of Systematic Reviews 2007, Issue 3. Art. No.: CD002851. DOI:10.1002/14651858.CD002851.pub3.

3. Cheung BS, Heskin R, Hofer KD. Failure of cetirizine and fexofenadine to prevent motion sickness. Ann Pharmacother. 2003;37:173–7.

4. Hershkovitz D, Asna N, Shupak A, et al. Ondansetron for the prevention of seasickness in susceptible sailors: an evaluation at sea. Aviat Space Environ Med. 2009;80:643–6.

5. Streitberger K, Ezzo J, Schneider A. Acupuncture for nausea and vomiting: an update of clinical and experimental studies. Auton Neuro. 2006;129:107–17.

6. Zajonc TP, Roland PS. Vertigo and motion sickness. Part II: Pharmacologic treatment. Ear Nose Throat J. 2006;85:25–35.

7. Spinks AB, Wasiak J, Villanueva EV, et al. Scopolamine (hyoscine) for preventing and treating motion sickness. Cochrane Database Syst Rev. 2007;CD002851.

Additional Reading

Carroll ID, Williams DC. Pre-travel vaccination and medical prophylaxis in the pregnant traveler. Travel Med Infect Dis. 2008;6:259–75.

See Also (Topic, Algorithm, Electronic Media Element)

Algorithm: Vertigo

Codes

ICD9

994.6 Motion sickness

Snomed

37031009 motion sickness (finding)

Clinical Pearls

The scopolamine patch should be applied at least 4 h before travel, although it may be more effective if placed 6–12 h before departure.Oral medications should be administered 30 min–1 h before departure.Although acupressure wrist bands have been found to be effective by systematic reviews in postoperative and chemotherapy-induced nausea and vomiting, conflicting data exist for motion sickness.