> Table of Contents > Motion Sickness
Motion Sickness
Courtney I. Jarvis, PharmD
Allison Hargreaves, MD
image BASICS
DESCRIPTION
  • Motions sickness is 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 proprioceptors.
  • Also can be induced when patterns of motion differ from those previously experienced
  • System affected: nervous
  • Synonym(s): car sickness; sea sickness; air sickness; space sickness; physiologic vertigo
EPIDEMIOLOGY
Incidence
Predominant sex: female > male
Prevalence
Estimation is complex; syndrome occurs in ˜25% due to travel by air, ˜29% by sea, and ˜41% by road. Estimates for vomiting are 0.5% by air, 7% by sea, and 2% by road.
ETIOLOGY AND PATHOPHYSIOLOGY
  • Precise etiology unknown; thought to be due to a mismatch of vestibular and visual sensations
  • Rotary, vertical, and low frequency motions produce more symptoms than linear, horizontal, and highfrequency motions.
  • Nausea and vomiting occur as a result of increased levels of dopamine and acetylcholine, which stimulate chemoreceptor trigger zone and vomiting center in CNS.
Genetics
Heritability estimates range from 55% to 75%.
RISK FACTORS
  • Motion (auto, plane, boat, amusement rides)
  • Travel
  • Visual stimuli (e.g., moving horizon)
  • Poor ventilation (fumes, smoke, carbon monoxide)
  • Emotions (fear, anxiety)
  • Zero gravity
  • Pregnancy, menstruation, oral contraceptive use
  • History of migraine headaches, especially vestibular migraine
  • Other illness or poor health
GENERAL PREVENTION
See “General Measures.”
Pediatric Considerations
  • Rare in children <2 years of age
  • Incidence peaks between 3 and 12 years of age.
  • Antihistamines may cause excitation in children.
Geriatric Considerations
  • Age confers some resistance to motion sickness.
  • Elderly are at increased risk of anticholinergic side effects from treatment.
Pregnancy Considerations
  • Pregnant patients are more likely to experience motion sickness.
  • Treat with medications is thought to be safe during morning sickness (e.g., meclizine, dimenhydrinate).
COMMONLY ASSOCIATED CONDITIONS
  • Migraine headache
  • Vestibular syndromes
image DIAGNOSIS
PHYSICAL EXAM
No specific findings
DIFFERENTIAL DIAGNOSIS
  • Mountain sickness
  • Vestibular disease, central and peripheral
  • Gastroenteritis
  • Metabolic disorders
  • Toxin exposure
DIAGNOSTIC TESTS & INTERPRETATION
None indicated
image 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) are not 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 first line due to sedation and addiction potential (6)[C].
  • Serotonin receptor agonist (rizatriptan) may be effective for migraineurs with motion sickness (7)[C].
GENERAL MEASURES
  • Avoid noxious types of motions.
  • Choose locations within vehicle that minimizes motion (airplanes: over the wing; automobiles: driver's or front passenger seat, facing forward; boat: facing towards the waves, away from rocking bow, near surface of the water; buses: near the front, at lowest level, facing forward; trains: at lowest level, facing forward).
  • Improve ventilation; avoid noxious stimuli.
  • Use semirecumbent seating or lay supine.
  • Fix vision on horizon; avoid fixation on moving objects; keep eyes fixed on still, distant objects.
  • Avoid reading while actively traveling.
  • Frequent and graded exposure to stimulus that triggers nausea (habituation).
  • Eat before travel, avoid empty stomach; eat light, soft, bland, low-fat, and low-acid foods; 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 (5)[B]
P.687

MEDICATION
First Line
  • Scopolamine transdermal patch (Transderm Scop): Apply 2.5-cm2 (4 mg) patch behind ear at least 4 hours (preferably 6 to 12 hours) before travel, and replace every 3 days (2)[A].
  • Dimenhydrinate (Dramamine): take 30 to 60 minutes before travel
    • Adults and adolescents: 50 to 100 mg q4-6h, maximum 400 mg/day
    • Children 6 to 12 years of age: 25 to 50 mg q6-8h, maximum 150 mg/day
    • Children 2 to 5 years of age: 12.5 to 25 mg q6-8h, maximum 75 mg/day
  • Meclizine (Antivert): take 60 minutes before travel
    • Adults and adolescents >12 years of age: 25 to 50 mg q24h
    • Children <12 years of age: not recommended
  • Diphenhydramine (Benadryl): take 30 to 60 minutes before travel
    • Adults and adolescents: 25 to 50 mg q6-8h, maximum 300 mg/day
    • Children 6 to 12 years of age: 5 mg/kg or 12.5 to 25 mg q6-8h, maximum 300 mg/day
  • Promethazine (Phenergan): take 30 to 60 minutes before travel
    • Adults and adolescents: 25 mg q12h; 25 to 50 mg IM if already developed severe motion sickness
    • Children 2 to 12 years of age: 0.5 mg/kg q12h, maximum 25 mg BID. Caution: increased risk of dystonic reaction in this age group
  • Contraindications: patients at risk for acute angleclosure glaucoma
  • Precautions:
    • Young children
    • Elderly
    • Pregnancy
    • Urinary obstruction
    • Pyloric-duodenal obstruction
  • Adverse reactions:
    • Drowsiness
    • Dry mouth
    • Blurred vision
    • Confusion
    • Headache
    • Urinary retention
  • Significant possible interactions:
    • Sedatives (antihistamines, alcohol, antidepressants)
    • Anticholinergics (belladonna alkaloids)
Second Line
  • Benzodiazepines: take 1 to 2 hours before travel
    • Diazepam 2 to 10 mg PO q6-12h
    • Lorazepam 1 to 2 mg PO q8h
  • Contraindications:
    • Severe respiratory dysfunction
    • Severe liver dysfunction
    • Precautions:
    • Alcohol/drug abuse
    • Elderly
    • Sedation
    • Addiction is possible.
COMPLEMENTARY & ALTERNATIVE MEDICINE
Ginger: 940 mg or 1 g; take 4 hours before travel (evidence controversial) (8)[B]
image ONGOING CARE
DIET
  • Eat before travel, avoid empty stomach; eat light, soft, bland, low-fat, and low-acid foods.
  • Avoid alcohol.
PROGNOSIS
  • Symptoms should resolve when motion exposure ends.
  • Resistance to motion sickness seems to increase with age.
REFERENCES
1. Brainard A, Gresham C. Prevention and treatment of motion sickness. Am Fam Physician. 2014;90(1):41-46.
2. Spinks AB, Wasiak J, Villanueva EV, et al. Scopolamine (hyoscine) for preventing and treating motion sickness. Cochrane Database Syst Rev. 2007;(3):CD002851.
3. Cheung BS, Heskin R, Hofer KD. Failure of cetirizine and fexofenadine to prevent motion sickness. Ann Pharmacother. 2003;37(2):173-177.
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(7):643-646.
5. Streitberger K, Ezzo J, Schneider A. Acupuncture for nausea and vomiting: an update of clinical and experimental studies. Auton Neurosci. 2006;129 (1-2):107-117.
6. Zajonc TP, Roland PS. Vertigo and motion sickness. Part II: pharmacologic treatment. Ear Nose Throat J. 2006;85(1):25-35.
7. Furman JM, Marcus DA, Balaban CD. Rizatriptan reduces vestibular-induced motion sickness in migraineurs. J Headache Pain. 2011;12(12):81-88.
8. White B. Ginger: an overview. Am Fam Physician. 2007;75(11):1689-1691.
Additional Reading
&NA;
Murdin L, Golding J, Bronstein A. Managing motion sickness. BMJ. 2011;343:d7430.
See Also
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Algorithm: Dizziness
Codes
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ICD10
T75.3XXA Motion sickness, initial encounter
Clinical Pearls
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  • The scopolamine patch should be applied at least 4 hours before travel, although it may be more effective if placed 6 to 12 hours before departure.
  • Oral medications should be administered 30 to 60 minutes before departure.
  • Although acupressure wristbands have been found to be effective by systematic reviews in postoperative and chemotherapy-induced nausea and vomiting, conflicting data exist for motion sickness.