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Chapter 2 The Pre-Travel Consultation Self-Treatable Conditions

Motion Sickness

Stefanie K. Erskine

RISK FOR TRAVELERS

Motion sickness is the term attributed to physiologic responses to motion by sea, car, train, air, and virtual reality immersion. Given sufficient stimulus all people with functional vestibular systems can develop motion sickness. However, people vary in their susceptibility. Risk factors include the following:

  • Age—children aged 2–12 years are especially susceptible, but infants and toddlers are generally immune. Adults older than 50 years are less susceptible to motion sickness.
  • Sex—women are more likely to have motion sickness, especially when pregnant, menstruating, or on hormones.
  • Race/ethnicity—Asians may be more susceptible to motion sickness than Europeans.
  • Migraines—people who get migraine headaches are more prone to motion sickness, especially during a migraine.
  • Medication—some prescriptions can worsen the nausea of motion sickness.

CLINICAL PRESENTATION

Travelers suffering from motion sickness commonly exhibit some or all of the following symptoms:

  • Nausea
  • Vomiting/retching
  • Sweating
  • Cold sweats
  • Excessive salivation
  • Apathy
  • Hyperventilation
  • Increased sensitivity to odors
  • Loss of appetite
  • Headache
  • Drowsiness
  • Warm sensation
  • General discomfort

PREVENTION

Nonpharmacologic interventions to prevent or treat motion sickness include the following:

  • Being aware of and avoiding situations that tend to trigger symptoms.
  • Optimizing position to reduce motion or motion perception—for example, driving a vehicle instead of riding in it, sitting in the front seat of a car or bus, sitting over the wing of an aircraft, holding the head firmly against the back of the seat, and choosing a window seat on flights and trains.
  • Reducing sensory input—lying prone, shutting eyes, sleeping, or looking at the horizon.
  • Maintaining hydration by drinking water, eating small meals frequently, and limiting alcoholic and caffeinated beverages.
  • Avoiding smoking—even short-term cessation reduces susceptibility to motion sickness.
  • Adding distractions—controlling breathing, listening to music, or using aromatherapy scents such as mint or lavender. Flavored lozenges may also help.
  • Using acupressure or magnets is advocated by some to prevent or treat nausea, although scientific data on efficacy of these interventions for preventing motion sickness are lacking.
  • Gradually exposing oneself to continuous or repeated motion sickness triggers. Most people, in time, notice a reduction in motion sickness symptoms.

TREATMENT

Nonpharmacologic treatments for preventing and treating motion sickness can be effective with few adverse side effects (see Prevention above). However, these measures can be time-consuming and unpleasant for travelers. Many patients will prefer medication.

Before deciding which medications to prescribe, consider factors such as individual susceptibility and type, magnitude, and duration of potential stimuli. Medications to treat motion sickness are most effective when taken before exposure.

A primary side effect of most efficacious medications used for motion sickness is drowsiness, along with other drug-specific side effects. Some medications may interfere with or delay acclimation to the offending movement. Because gastric stasis can occur with motion sickness, parenteral delivery may be advantageous.

Antihistamines are the most frequently used and widely available medications for motion sickness; non-sedating ones appear to be less effective. Antihistamines commonly used for motion sickness include cinnarizine (not currently available in the United States), cyclizine, dimenhydrinate, meclizine, and promethazine (oral and suppository). Other common medications used to treat motion sickness are anticholinergics such as scopolamine (hyoscine, oral, intranasal, and transdermal), antidopaminergic drugs (such as prochlorperazine), metoclopramide, sympathomimetics, and benzodiazepines. Clinical trials have not shown that ondansetron, a drug commonly used as an antiemetic in cancer patients, is effective in the prevention of nausea associated with motion sickness.

When recommending any of these medications to travelers, providers should make sure that patients understand the risks and benefits, possible undesirable side effects, and potential drug interactions. Travelers may consider trying the medication before travel to see what effect it has on them.

Medications in Children

For children aged 2–12 years, dimenhydrinate (Dramamine), 1–1.5 mg/kg per dose, or diphenhydramine (Benadryl), 0.5–1 mg/kg per dose up to 25 mg, can be given 1 hour before travel and every 6 hours during the trip. Because some children have paradoxical agitation with these medicines, a test dose should be given at home before departure.

Antihistamines are not approved by the Food and Drug Administration to treat motion sickness in children. Caregivers should be reminded to always ask a physician, pharmacist, or other clinician if they have any questions about how to use or dose antihistamines in children before they administer the medication. Oversedation of young children with antihistamines can be life-threatening.

Scopolamine can cause dangerous adverse effects in children and should not be used; prochlorperazine and metoclopramide should be used with caution in children.

Medications in Pregnancy

Drugs with the most safety data regarding the treatment of the nausea of pregnancy are the logical first choice. Alphabetical scoring of the safety of medications in pregnancy may not be helpful, and clinicians should review the actual safety data or call the patient’s obstetric provider for suggestions. Web-based information may be found at the websites www.Motherisk.org and www.Reprotox.org.

BIBLIOGRAPHY

  1. Golding JF, Gresty MA. Pathophysiology and treatment of motion sickness. Curr Opin Neurol. 2015 Feb;28(1):83–8.
  2. Murdin L, Golding J, Bronstein A. Managing motion sickness. BMJ. 2011 Dec 2;343:d7430.
  3. Priesol AJ. Motion sickness. Deschler DG, editor. Waltham MA: UpToDate; 2012.
  4. Schmäl F. Neuronal mechanisms and the treatment of motion sickness. Pharmacology. 2013 May;91(3-4):229–41.
  5. Shupak A, Gordon CR. Motion sickness: advances in pathogenesis, prediction, prevention, and treatment. Aviat Space Environ Med. 2006 Dec;77(12):1213–23.
  6. Zhang L, Wang J, Qi R, Pan L, Li M, Cai Y. Motion sickness: current knowledge and recent advance. CNS Neurosci Ther. 2016 Jan;22(1):15–24.
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