FPIN's Clinical Inquiries

Treatment of Motion Sickness



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Am Fam Physician. 2012 Jul 15;86(2):192-195.

Clinical Question

What is the best medication for the treatment of motion sickness?

Evidence-Based Answer

Scopolamine should be used to reduce nausea associated with motion sickness, but it does not reduce vomiting. (Strength of Recommendation [SOR]: A, based on multiple randomized controlled trials [RCTs].) First-generation antihistamines (dimenhydrinate and chlorpheniramine) can also be used to reduce nausea associated with motion sickness. (SOR: B, based on multiple RCTs.) Scopolamine is more effective than meclizine (Antivert) and as effective as dimenhydrinate. Ondansetron (Zofran) and the second-generation antihistamines cetirizine (Zyrtec) and fexofenadine (Allegra) do not reduce symptoms of motion sickness and should not be used. (SOR: B, based on small RCTs.) Ginger can be used to reduce symptoms of motion sickness. (SOR: B, based on RCTs with conflicting results.)

Evidence Summary

SCOPOLAMINE

A Cochrane review of 14 RCTs with a total of 1,025 participants who had sea- or lab-induced motion sickness compared scopolamine with placebo and various other agents.1 Scopolamine reduced nausea more than placebo (relative risk reduction = 0.47; 95% confidence interval, 0.31 to 0.71) but did not reduce vomiting. Patients receiving scopolamine were more likely to have dry mouth (a 22 to 50 percent increase). Three of the RCTs compared scopolamine with antihistamines. Two studies found scopolamine to be superior to meclizine, and one found it to be equivalent to dimenhydrinate.1

FIRST-GENERATION ANTIHISTAMINES

Numerous histamine H1 receptor antagonists are available over the counter and by prescription, including dimenhydrinate, chlorpheniramine, diphenhydramine (Benadryl), and meclizine. One small RCT (n = 16) found that dimenhydrinate reduced nausea scores more than placebo, and another found that high-dose (12-mg) chlorpheniramine reduced the risk of severe malaise more than placebo2,3  (Table 1110). A higher incidence of dry mouth was found with dimenhydrinate, and more sedation was reported with chlorpheniramine.

Table 1.

Randomized Controlled Trials of Motion Sickness Medications vs. Placebo

Medication Number of participants Motion stimulus Outcome measured Results

Scopolamine (various delivery methods)1

1,025

Sea- and lab-induced

Nausea

Relative risk reduction = 0.47* (95% confidence interval, 0.31 to 0.71)

Dimenhydrinate2

16

Lab-induced

Nausea symptom score (0 to 100)

60-point reduction in nausea score compared with 17-point reduction with placebo (P < .005)†

Chlorpheniramine (4 mg and 12 mg)3

18

Lab-induced

Rotating time, severe malaise

Increased rotating time in high- and low-dose groups; NNT = 4 in high-dose group (P = .01)‡

Cetirizine (Zyrtec), fexofenadine (Allegra)4

18

Lab-induced

Motion sickness scores

No significant difference

Ondansetron (Zofran)

605

Lab-induced

Rotating time, symptom scores

No significant difference

166

Sea-induced

Symptom scores

No significant difference

Ginger (1 g powdered root)7

79

Sea-induced

Vomiting, cold sweats, nausea, vertigo

NNT = 19 to prevent vomiting and cold sweats (P < .05)‡; no reduction in nausea or vertigo

Ginger (1- or 2-g capsules)8

18

Lab-induced

3-point nausea score, time to onset of nausea

1-point decrease in maximal nausea score (P < .05); 2.9- and 4.1-minute increase in time to onset of nausea (P < .05)†

Ginger (940 mg powdered root)9

36

Lab-induced

Rotating time

4.1-minute increase (P < .001)†

Ginger (500 to 1,000 mg powdered or fresh root)10

28

Lab-induced

Severe malaise

No significant difference


NNT = number needed to treat.

*—Raw data not available for calculation of NNT.

†—Continuous data; risk reductions and NNT not calculated.

‡—Confidence intervals were not reported.

Information from references 1 through 10.

Table 1.   Randomized Controlled Trials of Motion Sickness Medications vs. Placebo

View Table

Table 1.

Randomized Controlled Trials of Motion Sickness Medications vs. Placebo

Medication Number of participants Motion stimulus Outcome measured Results

Scopolamine (various delivery methods)1

1,025

Sea- and lab-induced

Nausea

Relative risk reduction = 0.47* (95% confidence interval, 0.31 to 0.71)

Dimenhydrinate2

16

Lab-induced

Nausea symptom score (0 to 100)

60-point reduction in nausea score compared with 17-point reduction with placebo (P < .005)†

Chlorpheniramine (4 mg and 12 mg)3

18

Lab-induced

Rotating time, severe malaise

Increased rotating time in high- and low-dose groups; NNT = 4 in high-dose group (P = .01)‡

Cetirizine (Zyrtec), fexofenadine (Allegra)4

18

Lab-induced

Motion sickness scores

No significant difference

Ondansetron (Zofran)

605

Lab-induced

Rotating time, symptom scores

No significant difference

166

Sea-induced

Symptom scores

No significant difference

Ginger (1 g powdered root)7

79

Sea-induced

Vomiting, cold sweats, nausea, vertigo

NNT = 19 to prevent vomiting and cold sweats (P < .05)‡; no reduction in nausea or vertigo

Ginger (1- or 2-g capsules)8

18

Lab-induced

3-point nausea score, time to onset of nausea

1-point decrease in maximal nausea score (P < .05); 2.9- and 4.1-minute increase in time to onset of nausea (P < .05)†

Ginger (940 mg powdered root)9

36

Lab-induced

Rotating time

4.1-minute increase (P < .001)†

Ginger (500 to 1,000 mg powdered or fresh root)10

28

Lab-induced

Severe malaise

No significant difference


NNT = number needed to treat.

*—Raw data not available for calculation of NNT.

†—Continuous data; risk reductions and NNT not calculated.

‡—Confidence intervals were not reported.

Information from references 1 through 10.

SECOND-GENERATION ANTIHISTAMINES

One RCT with 18 healthy participants evaluated the second-generation, nonsedating antihistamines cetirizine and fexofenadine in lab-induced motion sickness, and found no statistically significant difference in motion sickness scores compared with placebo.4

ONDANSETRON

Two well-designed RCTs that included a total of 86 participants with sea- or lab-induced motion sickness found that ondansetron did not reduce motion sickness symptoms compared with placebo.5,6

GINGER

Two higher-quality, placebo-controlled RCTs found that ginger reduced vomiting (but not nausea) in the larger trial, and delayed the onset and reduced the intensity of nausea in the smaller trial.7,8 Two older RCTs comparing ginger with placebo for lab-induced motion sickness produced conflicting results; one found that ginger delayed the onset of nausea, whereas the other found no difference in severe malaise.9,10

Recommendations from Others

Based on a summary of the evidence and expert opinion, UpToDate recommends the use of sedating antihistamines, scopolamine, or ginger for the treatment of motion sickness.11

Address correspondence to Matthew Sutton, MD, at msutton@unch.unc.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations to disclose.


Copyright Family Physicians Inquiries Network. Used with permission.

REFERENCES

1. Spinks A, Wasiak J. Scopolamine (hyoscine) for preventing and treating motion sickness Cochrane Database Syst Rev. 2011(6):CD002851.

2. Pyykkö I, Schalén L, Jäntti V. Transdermally administered scopolamine vs. dimenhydrinate. I. Effect on nausea and vertigo in experimentally induced motion sickness. Acta Otolaryngol. 1985;99(5–6):588–596.

3. Buckey JC, Alvarenga D, Cole B, Rigas JR. Chlorpheniramine for motion sickness. J Vestib Res. 2004;14(1):53–61.

4. Cheung BS, Heskin R, Hofer KD. Failure of cetirizine and fexofenadine to prevent motion sickness. Ann Pharmacother. 2003;37(2):173–177.

5. Muth ER, Elkins AN. High dose ondansetron for reducing motion sickness in highly susceptible subjects. Aviat Space Environ Med. 2007;78(7):686–692.

6. Hershkovitz D, Asna N, Shupak A, Kaminski G, Bar R, Tal D. Ondansetron for the prevention of seasickness in susceptible sailors: an evaluation at sea. Aviat Space Environ Med. 2009;80(7):643–646.

7. Grøntved A, Brask T, Kambskard J, Hentzer E. Ginger root against seasickness. A controlled trial on the open sea. Acta Otolaryngol. 1988;105(1–2):45–49.

8. Lien HC, Sun WM, Chen YH, Kim H, Hasler W, Owyang C. Effects of ginger on motion sickness and gastric slow-wave dysrhythmias induced by circular vection. Am J Physiol Gastrointest Liver Physiol. 2003;284(3):G481–G489.

9. Mowrey DB, Clayson DE. Motion sickness, ginger, and psychophysics. Lancet. 1982;1(8273):655–657.

10. Stewart JJ, Wood MJ, Wood CD, Mims ME. Effects of ginger on motion sickness susceptibility and gastric function. Pharmacology. 1991;42(2):111–120.

11. Priesol AJ. Motion sickness. UpToDate, Inc. http://www.uptodate.com/contents/motion-sickness [subscription required]. Accessed May 14, 2012.

Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (http://www.cebm.net/?o=1025).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to http://www.fpin.org or email: questions@fpin.org.

A collection of FPIN's Clinical Inquiries published in AFP is available at http://www.aafp.org/afp/fpin.


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