Prevention and Treatment of Motion Sickness


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Am Fam Physician. 2014 Jul 1;90(1):41-46.

  Patient information: See related handout on motion sickness, written by the authors of this article.

Motion sickness is a common syndrome that occurs upon exposure to certain types of motion. It is thought to be caused by conflict between the vestibular, visual, and other proprioceptive systems. Although nausea is the hallmark symptom, it is often preceded by stomach awareness, malaise, drowsiness, and irritability. Early self-diagnosis should be emphasized, and patients should be counseled about behavioral and pharmacologic strategies to prevent motion sickness before traveling. Patients should learn to identify situations that will lead to motion sickness and minimize the amount of unpleasant motion they are exposed to by avoiding difficult conditions while traveling or by positioning themselves in the most stable part of the vehicle. Slow, intermittent exposure to the motion can reduce symptoms. Other behavioral strategies include watching the true visual horizon, steering the vehicle, tilting their head into turns, or lying down with their eyes closed. Patients should also attempt to reduce other sources of physical, mental, and emotional discomfort. Scopolamine is a first-line medication for prevention of motion sickness and should be administered transdermally several hours before the anticipated motion exposure. First-generation antihistamines, although sedating, are also effective. Nonsedating antihistamines, ondansetron, and ginger root are not effective in the prevention and treatment of motion sickness.

Motion sickness is a syndrome that occurs when a patient is exposed to certain types of motion and usually resolves soon after its cessation. It is a common response to motion stimuli during travel. Although nausea is a hallmark symptom, the syndrome includes symptoms ranging from vague malaise to completely incapacitating illness. These symptoms, which can affect the patient's recreation, employment, and personal safety, can occur within minutes of experiencing motion and can last for several hours after its cessation.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

To prevent and reduce symptoms of motion sickness, passengers should look forward at a fixed point on the horizon and avoid close visual tasks.

C

25

To prevent and reduce symptoms of motion sickness in vehicles, passengers should actively steer, tilt their head into turns, recline, stabilize their head and body, or rest with their eyes closed.

C

68

Scopolamine should be a first-line medication for preventing motion sickness in persons who wish to maintain wakefulness during travel.

A

1, 2, 14, 15, 20, 21, 24

First-generation antihistamines are effective for preventing motion sickness, but often have sedative and other side effects.

B

1, 2, 16, 17, 1921, 26


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

To prevent and reduce symptoms of motion sickness, passengers should look forward at a fixed point on the horizon and avoid close visual tasks.

C

25

To prevent and reduce symptoms of motion sickness in vehicles, passengers should actively steer, tilt their head into turns, recline, stabilize their head and body, or rest with their eyes closed.

C

68

Scopolamine should be a first-line medication for preventing motion sickness in persons who wish to maintain wakefulness during travel.

A

1, 2, 14, 15, 20, 21, 24

First-generation antihistamines are effective for preventing motion sickness, but often have sedative and other side effects.

B

1, 2, 16, 17, 1921, 26


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Nearly all persons will have symptoms in response to severe motion stimuli, and a history of motion sickness best predicts future symptoms.1 Females, children two to 15 years of age, and persons with conditions associated with nausea (e.g., early pregnancy, migraines, vestibular syndromes) report increased susceptibility.

Etiology

The pathogenesis of motion sickness is not clearly understood, but it is thought to be related to conflict between the vestibular, visual, and other proprioceptive systems.2 Rotary, vertical, and low-frequency motions produce more symptoms than linear, horizontal, and high-frequency motions.1

Clinical Presentation

Although nausea may be the first recognized symptom of motion sickness, it is almost always preceded by other subtle symptoms such as stomach awareness (i.e., a sensation of fullness in the epigastrium), malaise, drowsiness, and irritability. Failure to attribute early symptoms to motion sickness may lead to delays in diagnosis and treatment. Although mild symptoms are common, severely debilitating symptoms are rare2 (Table 11,2).

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Table 1.

Signs and Symptoms of Motion Sickness

SeveritySignsSymptoms

Mild

Belching

Yawning

Facial and perioral pallor

Heartburn

Hypersalivation

Urinary frequency

Stomach awareness

Malaise

Headache

Irritability

Drowsiness

Fatigue

Moderate

Cold diaphoresis

Flushing

Increased body warmth

Hyperventilation

Vomiting

Nausea

Nonvertiginous dizziness

Apathy

Depression

Disinterest in social activities

Disinclination for work

Decreased cognitive performance

Exaggerated sense of motion

Increased postural sway

Severe

Inability to walk

Incapacitation

Loss of postural stability

Persistent retching

Social isolation


note: Signs and symptoms are listed in decreasing order of prevalence.

Information from references 1 and 2.

Table 1.

Signs and Symptoms of Motion Sickness

SeveritySignsSymptoms

Mild

Belching

Yawning

Facial and perioral pallor

Heartburn

Hypersalivation

Urinary frequency

Stomach awareness

Malaise

Headache

Irritability

Drowsiness

Fatigue

Moderate

Cold diaphoresis

Flushing

Increased body warmth

Hyperventilation

Vomiting

Nausea

Nonvertiginous dizziness

Apathy

Depression

Disinterest in social activities

Disinclination for work

Decreased cognitive performance

Exaggerated sense of motion

Increased postural sway

Severe

Inability to walk

Incapacitation

Loss of postural stability

Persistent retching

Social isolation


note: Signs and symptoms are listed in decreasing order of prevalence.

Information from references 1 and 2.

Behavioral Interventions

Prevention of motion sickness is more effective than treating symptoms after they have occurred. Therefore, patients should learn to identify situations that may lead to motion sickness and be able to initiate behavioral strategies to prevent or minimize symptoms1,2 (Table 2113).

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Table 2.

Behavioral Strategies to Prevent or Minimize Symptoms of Motion Sickness

General principleTactics

Minimize vestibular motion

Avoid particularly noxious types of motions

Complex (multiple and off-axis) motions are worse than simple (one-axis) motions

Low-frequency motions are worse than high-frequency motions

Rotary motion is worse than linear motion

Vertical motions are worse than horizontal motions

Avoid travel in difficult conditions and locations

Avoid air travel in storms and turbulent conditions

Avoid terrain with many turns, accelerations, and ups and downs

Avoid travel on water in storms and large waves

Avoid travel through fog, clouds, and other conditions with poor visibility

Choose location within the vehicle that minimizes motion

Airplanes: over the wing

Automobiles: driver's or front passenger seat, facing forward3,4

Boats: facing toward the waves, away from the rocking bow, near the surface of the water2

Buses: near the front, at the lowest level, facing forward3

Trains: at the lowest level, facing forward

Habituate to motion

Gradually increase amount of motion stimuli

Start travel in calm conditions and slowly increase the amount of motion exposure

If symptomatic, attempt to reduce, but not eliminate, motion stimuli

Synchronize the visual system with the motion

View the true visual horizon25

Avoid close work (e.g., reading, looking at computer screens, photography)

Avoid spaces where the horizon cannot be seen

Focus on a distant point on the horizon

Look toward the motion or direction of travel

Maintain a wide view of the horizon

If unable to view the true visual horizon

Close eyes and hold head still

Wear sunglasses

Actively synchronize the body with the motion

Perform active movements if possible

Actively tilt head into turns6

Pilot the vehicle or connect with steering device7

Stand with legs bent, and anticipate the motion by moving entire body

Actively swim if in water

Walk around the vehicle if possiblePerform active movements if possible

If unable to perform active movements

Brace body and head to avoid additional motion8

Lay supine or recline head to 30 degrees

Reduce other sources of physical, mental, and emotional discomfort

Treat and prevent gastritis2

Avoid alcoholic drinks

Eat before traveling, and avoid an empty stomach

Eat light, soft, bland, low-fat, and low-acid food

Stay or get comfortable2

Attempt to sleep

Avoid dehydration, hunger, and fatigue

Stay dry

Avoid or reduce other unpleasant stimuli

Assure adequate ventilation

Avoid discussing motion sickness

Avoid noxious stimuli (e.g., exhaust fumes, smell of emesis)

Avoid unpleasant thoughts9

Listen to music10

Maintain a positive attitude11,12

Use cognitive behavior therapy2

Practice mindful breathing13


Information from references 1 through 13.

Table 2.

Behavioral Strategies to Prevent or Minimize Symptoms of Motion Sickness

General principleTactics

Minimize vestibular motion

Avoid particularly noxious types of motions

Complex (multiple and off-axis) motions are worse than simple (one-axis) motions

Low-frequency motions are worse than high-frequency motions

Rotary motion is worse than linear motion

Vertical motions are worse than horizontal motions

Avoid travel in difficult conditions and locations

Avoid air travel in storms and turbulent conditions

Avoid terrain with many turns, accelerations, and ups and downs

Avoid travel on water in storms and large waves

Avoid travel through fog, clouds, and other conditions with poor visibility

Choose location within the vehicle that minimizes motion

Airplanes: over the wing

Automobiles: driver's or front passenger seat, facing forward3,4

Boats: facing toward the waves, away from the rocking bow, near the surface of the water2

Buses: near the front, at the lowest level, facing forward3

Trains: at the lowest level, facing forward

Habituate to motion

Gradually increase amount of motion stimuli

Start travel in calm conditions and slowly increase the amount of motion exposure

If symptomatic, attempt to reduce, but not eliminate, motion stimuli

Synchronize the visual system with the motion

View the true visual horizon25

Avoid close work (e.g., reading, looking at computer screens, photography)

Avoid spaces where the horizon cannot be seen

Focus on a distant point on the horizon

Look toward the motion or direction of travel

Maintain a wide view of the horizon

If unable to view the true visual horizon

Close eyes and hold head still

Wear sunglasses

Actively synchronize the body with the motion

Perform active movements if possible

Actively tilt head into turns6

Pilot the vehicle or connect with steering device7

Stand with legs bent, and anticipate the motion by moving entire body

Actively swim if in water

Walk around the vehicle if possiblePerform active movements if possible

If unable to perform active movements

Brace body and head to avoid additional motion8

Lay supine or recline head to 30 degrees

Reduce other sources of physical, mental, and emotional discomfort

Treat and prevent gastritis2

Avoid alcoholic drinks

Eat before traveling, and avoid an empty stomach

Eat light, soft, bland, low-fat, and low-acid food

Stay or get comfortable2

Attempt to sleep

Avoid dehydration, hunger, and fatigue

Stay dry

Avoid or reduce other unpleasant stimuli

Assure adequate ventilation

Avoid discussing motion sickness

Avoid noxious stimuli (e.g., exhaust fumes, smell of emesis)

Avoid unpleasant thoughts9

Listen to music10

Maintain a positive attitude11,12

Use cognitive behavior therapy2

Practice mindful breathing13


Information from references 1 through 13.

MINIMIZE VESTIBULAR MOTION

Patients should be advised to avoid traveling in difficult weather conditions. If they must travel, they should sit in the part of the vehicle with the least amount of rotational and vertical motion.2 This is usually the lowest level in trains and buses, close to water level and in the center of boats, and over the wing on airplanes.

HABITUATE TO MOTION

With continuous exposure to motion, symptoms of motion sickness will usually subside in one to two days. Alternatively, slow, intermittent habituation to motion is an effective strategy to reduce symptoms.1 For example, spending the first night aboard a boat in the marina, followed by a day acclimating in the harbor, is preferable to going straight into the open ocean.

SYNCHRONIZE THE VISUAL SYSTEM WITH THE MOTION

A small study found that focusing on the true horizon (skyline) minimized symptoms of motion sickness.5 A survey of 3,256 bus passengers suggested that forward vision was helpful in reducing symptoms.3 Another study indicated that forward vision in a car can reduce symptoms.4

ACTIVELY SYNCHRONIZE THE BODY WITH THE MOTION

Actively steering the vehicle is an accepted strategy for reducing symptoms of motion sickness, although evidence is limited.7 Additionally, a small study of automobile passengers found that actively tilting the head into turns was effective in preventing symptoms.6 A survey of 260 cruise ship passengers supported the common advice to recline and passively stabilize themselves if they are unable to initiate active movements.8

REDUCE OTHER SOURCES OF PHYSICAL, MENTAL, AND EMOTIONAL DISCOMFORT

Frequent consumption of light, soft, bland, low-fat, and low-acid food can minimize symptoms of motion sickness.2 Treating gastritis is useful,2 as is avoiding nausea-inducing stimuli (e.g., alcohol, noxious odors). Discussing symptoms with others can exacerbate the condition. Passengers should be well rested, well hydrated, well fed, and comfortable before beginning travel. Small studies have shown that cognitive behavior therapy, mindful breathing, and listening to music may also reduce symptoms of motion sickness.9,10,13

Medications

Medications are most effective when taken prophylactically before traveling, or as soon as possible after the onset of symptoms2 (Table 31,2,1423). Medications are most effective when combined with behavioral strategies. To familiarize themselves with common side effects, patients should first take medications in a comfortable environment before using them for motion sickness during travel.

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Table 3.

Medications for Motion Sickness

MedicationEffectiveness for preventionDosageCommentsSide effects*

Anticholinergic

Scopolamine1416

Transdermal: most effective

Transdermal: one patch applied to mastoid at least four hours before travel, then every 72 hours as needed

First-line medication for prevention; transdermal formulation available by prescription; oral formulation not available in the United States; causes more dry eyes and dry mouth than antihistamines, but less sedation; may double dose or combine with antihistamines, or combine oral and transdermal formulations (increased risk of side effects); use with caution in older patients; not recommended for children younger than 10 years

Common: dry eyes, dry mouth, sensitivity to bright light

Less common: blurred vision, dizziness, headache, sedation

Uncommon: acute angle glaucoma, confusion, contact dermatitis, monocular pupillary dilation urinary retention

Oral: moderately effective

Oral: 0.4 to 0.6 mg one hour before travel, then every eight hours as needed

Antihistamines (first-generation, listed from least to most sedating)

Cinnarizine15

Moderately effective

Adults and children older than 12 years: 30 mg two hours before travel, then 15 mg every eight hours as needed

Children five to 12 years of age: 15 mg two hours before travel, then 7.5 to 15 mg every eight hours as needed

Available over the counter in Mexico and Europe; not available in the United States or Canada; has calcium channel–blocking properties

Class effects

Very common: sedation

Common: dry eyes, dry mouth

Less common: blurred vision, sensitivity to bright light

Uncommon: confusion, urinary retention

:

Cyclizine (Marezine)17

Least effective

Adults and children older than 12 years: 50 mg one hour before travel, then every four to six hours as needed (maximum: 200 mg per day)

Children six to 11 years of age: 25 mg one hour before travel, then every six to eight hours as needed (maximum: 75 mg per day)

Available over the counter

Dimenhydrinate16,18

Least effective

Adults and children older than 12 years: 50 to 100 mg every four to six hours (maximum: 400 mg per day)

Children six to 12 years of age: 25 to 50 mg every six to eight hours as needed (maximum: 150 mg per day)

Available over the counter

Diphenhydramine

Least effective

Adults and children older than 12 years: 25 to 50 mg every four to six hours (maximum: 300 mg per day)

Children six to 12 years of age: 12.5 to 25 mg every four to six hours as needed (maximum: 150 mg per day)

Oral formulations available over the counter; solution for intramuscular administration available by prescription

Promethazine16,19

Moderately effective

Adults: 25 mg 30 to 60 minutes before travel, then every 12 hours as needed

Children: 12.5 to 25 mg twice daily as needed

Prescription only; also available as rectal suppositories and as solution for intramuscular injection

Meclizine (Antivert)16,18

Least effective

Adults and children 12 years and older: 25 to 50 mg one hour before travel, then every 24 hours as needed

Children younger than 12 years: not recommended

Available over the counter


*—Most side effects are dose-related.

Information from references 1, 2, and 14 through 23.

Table 3.

Medications for Motion Sickness

MedicationEffectiveness for preventionDosageCommentsSide effects*

Anticholinergic

Scopolamine1416

Transdermal: most effective

Transdermal: one patch applied to mastoid at least four hours before travel, then every 72 hours as needed

First-line medication for prevention; transdermal formulation available by prescription; oral formulation not available in the United States; causes more dry eyes and dry mouth than antihistamines, but less sedation; may double dose or combine with antihistamines, or combine oral and transdermal formulations (increased risk of side effects); use with caution in older patients; not recommended for children younger than 10 years

Common: dry eyes, dry mouth, sensitivity to bright light

Less common: blurred vision, dizziness, headache, sedation

Uncommon: acute angle glaucoma, confusion, contact dermatitis, monocular pupillary dilation urinary retention

Oral: moderately effective

Oral: 0.4 to 0.6 mg one hour before travel, then every eight hours as needed

Antihistamines (first-generation, listed from least to most sedating)

Cinnarizine15

Moderately effective

Adults and children older than 12 years: 30 mg two hours before travel, then 15 mg every eight hours as needed

Children five to 12 years of age: 15 mg two hours before travel, then 7.5 to 15 mg every eight hours as needed

Available over the counter in Mexico and Europe; not available in the United States or Canada; has calcium channel–blocking properties

Class effects

Very common: sedation

Common: dry eyes, dry mouth

Less common: blurred vision, sensitivity to bright light

Uncommon: confusion, urinary retention

:

Cyclizine (Marezine)17

Least effective

Adults and children older than 12 years: 50 mg one hour before travel, then every four to six hours as needed (maximum: 200 mg per day)

Children six to 11 years of age: 25 mg one hour before travel, then every six to eight hours as needed (maximum: 75 mg per day)

Available over the counter

Dimenhydrinate16,18

Least effective

Adults and children older than 12 years: 50 to 100 mg every four to six hours (maximum: 400 mg per day)

Children six to 12 years of age: 25 to 50 mg every six to eight hours as needed (maximum: 150 mg per day)

Available over the counter

Diphenhydramine

Least effective

Adults and children older than 12 years: 25 to 50 mg every four to six hours (maximum: 300 mg per day)

Children six to 12 years of age: 12.5 to 25 mg every four to six hours as needed (maximum: 150 mg per day)

Oral formulations available over the counter; solution for intramuscular administration available by prescription

Promethazine16,19

Moderately effective

Adults: 25 mg 30 to 60 minutes before travel, then every 12 hours as needed

Children: 12.5 to 25 mg twice daily as needed

Prescription only; also available as rectal suppositories and as solution for intramuscular injection

Meclizine (Antivert)16,18

Least effective

Adults and children 12 years and older: 25 to 50 mg one hour before travel, then every 24 hours as needed

Children younger than 12 years: not recommended

Available over the counter


*—Most side effects are dose-related.

Information from references 1, 2, and 14 through 23.

SCOPOLAMINE

Scopolamine, an anticholinergic, is a first-line option for preventing motion sickness in persons who wish to maintain wakefulness during travel.2,20,24 A Cochrane review of 14 randomized controlled trials (RCTs) showed that scopolamine is effective for the prevention of motion sickness.14 A more recent RCT of 76 naval crew members showed that transdermal scopolamine is more effective and has fewer side effects than the antihistamine cinnarizine (not available in the United States).15 If the recommended dose of scopolamine does not adequately relieve symptoms, the dose may be doubled. Adding a second patch of transdermal scopolamine was well tolerated in a small RCT of 20 sailors.25

ANTIHISTAMINES

First-generation antihistamines have been used to treat motion sickness since the 1940s.1 They are generally recommended for patients who can tolerate their sedative effects.2,20 Cyclizine (Marezine), dimenhydrinate, promethazine, and meclizine (Antivert) demonstrated effectiveness in small RCTs of varying quality.1619 Nonsedating antihistamines are not effective in preventing or treating motion sickness.26

OTHER MEDICATIONS

Benzodiazepines are occasionally administered for severe symptoms of motion sickness and have been proven effective in a single small study.27 The serotonin agonist rizatriptan (Maxalt) reduced motion sickness symptoms in a single RCT of 25 patients with recurrent migraines.28 The serotonin antagonist ondansetron (Zofran) is ineffective for the prevention and treatment of motion sickness.29,30

COMPLEMENTARY AND ALTERNATIVE THERAPIES

Although ginger root is often reported to prevent motion sickness, it had no statistically significant effects in an RCT of 80 naval cadets.31 A single RCT of pregnant women showed that stimulation of the P6 acupressure point on the anterior wrist increased their tolerance of motion stimuli.32 Controlled trials of behavioral, pharmacologic, or alternative therapies for motion sickness have demonstrated strong placebo effects. Therefore, treatments are likely to be most effective if the patient believes that they will work.11,12

Data Sources: PubMed was searched using the MeSH headings motion sickness, ships, movement, space motion sickness, and travel. Additional searches were performed in Essential Evidence Plus, UpToDate, Medscape, and BMJ Clinical Evidence. Search dates: March 2012 through March 2014.

The Authors

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ANDREW BRAINARD, MD, MPH, FACEM, FACEP, is an emergency medicine physician at Middlemore Hospital, Auckland, New Zealand. He is co-director of emergency medical education for Middlemore Emergency Department and a senior lecturer at the University of Auckland School of Medicine....

CHIP GRESHAM, MD, FACEM, FAAEM, is an emergency medicine physician and medical toxicologist at Middlemore Hospital. He is the clinical director of medication safety at Middlemore Hospital, and a senior lecturer at the University of Auckland School of Medicine.

Author disclosure: No relevant financial affiliations.

Address correspondence to Andrew Brainard, MD, MPH, Middlemore Hospital, 100 Hospital Rd., Papatoetoe, Auckland, New Zealand, 2025 (e-mail: abrainard01@gmail.com). Reprints are not available from the authors.

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