Motion Sickness
Derek McCoy
Mark I. Harwood
BasicsDescription
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Not a true “sickness” but a situation in which there is a sensory conflict about body position among the visual receptors, vestibular receptors, and body proprioceptors. It can also be induced when patterns of motion differ from those previously experienced.
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Also can be induced when patterns of motion differ from those previously experienced
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System(s) affected: Nervous
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Synonym(s): Car sickness; Sea sickness; Air sickness
Epidemiology
Incidence
Predominant sex: Female > Male
Risk Factors
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Motion
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Travel
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Visual stimuli (ie, moving horizon)
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Poor ventilation (fumes, smoke, carbon monoxide)
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Emotions (fear, anxiety)
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Zero gravity
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Pregnancy
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Age
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Gender (Females > Males [1.7:1])
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Other illness or poor health
General Prevention
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Pediatric alert:
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Rare in children <2 yrs of age
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Incidence peaks between the ages of 3 and 12 yrs
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Antihistamines may cause excitation in children.
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Gerontologic alert:
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Age confers some resistance to motion sickness.
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Elderly at increased risk of anticholinergic side effects from treatment
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Pregnancy alert:
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Pregnant patients more likely to experience motion sickness
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Treat with medications thought to be safe during morning sickness (eg, meclizine, dimenhydrinate).
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Prevention/avoidance:
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Minimize exposure (seat in middle of plane or boat)
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Improve ventilation
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Semirecumbent seating
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Fix vision at 450-degree angle above horizon
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Avoid fixation of vision on moving objects (ie, waves)
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Avoid reading while traveling.
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Minimize food intake prior to travel.
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Etiology
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Precise etiology unknown; thought to be due to a mismatch of vestibular and visual sensations
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Nausea and vomiting occur as a result of increased levels of dopamine and acetylcholine, which stimulate chemoreceptor trigger zone and vomiting center in CNS.
DiagnosisPhysical Exam
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Nausea
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Vomiting
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Diaphoresis
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Pallor
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Hypersalivation
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Yawning
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Hyperventilation
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Anxiety
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Panic
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Malaise
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Fatigue
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Weakness
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Confusion
Differential Diagnosis
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Mountain sickness
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Vestibular disease
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Gastroenteritis
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Metabolic disorders
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Toxin exposure
Treatment-
Premedicate before travel with antidopaminergic, anticholinergic, or antihistamine agents.
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For extended travel, consider treatment with scopolamine transdermal patch.
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2nd-generation (nonsedating) antihistamines are not effective at preventing motion sickness.
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Serotonin (5-HT3) antagonists (eg, ondansetron) do not appear effective in preventing motion sickness.
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Conflicting data exist on the efficacy of acupressure for nausea and vomiting associated with motion sickness.
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Benzodiazepines suppress vesibular nuclei, but would not be considered 1st line owing to sedation and addiction potential.
P.397
Medication
First Line
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Scopolamine transdermal where available; apply patch 6 hr before travel and replace every 3 days or 0.4 mg to 0.8 mg PO q.i.d. PRN with 1st dose 1 hr prior to event (1)[C]
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Dimenhydrinate (Dramamine) given 30 min prior to motion; adults and adolescents 25–50 mg q4–6h, maximum 300 mg/day; children 6–12 yrs 12.5–25 mg q4–6h, maximum 150 mg/day; children 2–5 yrs 6.25 mg PO/IM/IV q4–6h, maximum 37.5 mg/day (1)[C]
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Meclizine (Antivert) 25–50 mg q24h Start 1 hr prior to travel (1)[C]
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Contraindications: Glaucoma, hypersensitivity to drug class
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Precautions:
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Young children
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Elderly
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Pregnancy
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Urinary obstruction
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Pyloric obstruction
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Significant possible interactions:
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Sedatives (antihistamines, alcohol, antidepressants)
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Anticholinergics (belladonna alkaloids)
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Adverse reactions:
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Drowsiness
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Dry mouth
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Blurred vision
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Confusion
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Headache
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Urinary retention
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Second Line
Ginger: 1 g PO Take 4 hr prior to travel (2)[C].
Additional Treatment
Additional Therapies
Stimulation of the P6 (pericardium 6) acupressure point with placement of fingers (3)[D]
Ongoing CareDiet
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Decrease oral intake or small frequent feedings
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Avoid alcohol
Prognosis
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Symptoms should resolve when motion exposure ends.
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Resistance to motion sickness seems to increase with age.
Complications
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Hypotension
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Dehydration
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Depression
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Panic or anxiety
References
1. Nachum Z, Shupak A, Gordon C. Transdermal scopolamine for prevention of motion sickness. Clinical Phamacokinetics. 2006;45:543–566.
2. White B. Ginger: An overview. American Family Physician. 2007;75:1689–1691.
3. Miller K, Muth E. Efficacy of acupressure and acustimulation bands for the prevention of motion sickness. Aviation, Space and Environmental Medicine. 2004;75:227–234.
Additional Reading
Dundee JW, McMillan C. Positive evidence for P6 acupuncture antiemesis. Postgrad Med. 1991;67:417–422.
Joseph J, Griffin M. Motion sickness: effect of changes in magnitude of combined lateral and roll oscillation. Aviation, Space Environ Med. 2008;79:1019–1027.
Klosterhalfen S, et al. Nausea induced by vection drum: contributions of body position, visual pattern, and gender. Aviation, Space Environ Med. 2008;79:384–389.
Kohl RL, Calkins DS. Control of nausea & autonomic dysfunction with terfenadine, a peripherally acting antihistamine. Aviation, Space Environ Med. 1991;62(5):392–396.
Shupak A, Gordon C. Motion Sickness: Advances in Pathogenesis, Prediction, Prevention, and Treatment. Aviation, Space Environ Med. 2006;77:1213–1223.
CodesICD9
994.6 Motion sickness
Clinical Pearls
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Nonpharmacologic means for prevention should be tried 1st, which include sitting in the front of moving objects and toward the middle of the vehicle, if possible. Improving ventilation and sitting semirecumbent may be helpful. In addition, avoidance of food prior to travel and avoidance of reading during travel are recommended. It is also recommended to avoid visual fixation on moving objects.
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The preferred treatment method is pretreatment with scopolamine transdermal, dimenhydrinate, or meclizine. Alternatively, acupressure (P6), ginger, or promethazine can be tried. If motion sickness develops, removing the noxious stimulus is curative for that exposure.