The treatment of CVS is complicated by a limited understanding of its pathophysiology and the lack of large systematic randomized, controlled trials. Given the absence of conclusive scientifically proven treatments, empirical guidelines have been developed (Li et al. 2008). Known precipitating factors such as chocolate, cheese, or MSG should be avoided when possible (Chow and Goldman 2007; Li and Misiewicz 2003). When anxiety or stress has been identified as a precipitant, the following may be preventive: psychotherapeutic treatment, the use of relaxation training and related self-management strategies, and the use of anxiolytics (Chow and Goldman 2007). When attacks occur more than once per month, prophylactic medication is also rec ommended (Chow and Goldman 2007; Li and Misiewicz 2003). Migraine prophylactic medications are commonly used, including tricyclic antidepres-sants, cyproheptadine, propranolol, and divalproex sodium (Chow and Goldman 2007; Li and Misiewicz 2003). Existing recommendations (Li et al. 2008) favor the following: use of cyproheptadine as prophylaxis in children ages 5 years and younger, with low-dose amitriptyline, a tricyclic antidepres-sant, recommended for those older than 5 years; the beta-blocker propranolol as a second choice at both younger and older ages; and complementary nutritional therapies with carnitine or coenzyme Q, which have also been used with little empirical data.
Once an episode of CVS has started, over 50% of children will require intravenous rehydration to avoid dehydration and acidosis (Chow and Goldman 2007; Li and Misiewicz 2003). Supportive measures include placing the child in a quiet, less stimulating environment and avoiding bright lighting, along with the use of antiemetics such as on-dansetron and sedatives such as lorazepam (Chow and Goldman 2007; Li and Misiewicz 2003; Li et al. 2008). The off-label use of triptans such as suma-triptan has been suggested as potentially helpful in the management of acute CVS episodes when administered early. Antipsychotic medications such as prochlorperazine have been demonstrated to be efficacious in the management of acute migraine (Siow et al. 2005) and have shown promise in the management of intractable pediatric migraine (Kab-bouche et al. 2001), raising questions about their potential utility in CVS, but clinical experience has apparently been uninspiring (Li et al. 2008). The use of proton pump inhibitors to prevent heartburn and dyspepsia has also been advocated during acute episodes. Due to the severe stress that a recurrent disabling condition can place on families, awareness of support and informational resources such as the Cyclic Vomiting Syndrome Association (http:// www.cvsaonline.org) may be helpful, and formal family therapy may prove useful in some instances to help families and patients deal with the stress of illness and to prevent this stress from becoming a precipitant (Chow and Goldman 2007; Li and Misiewicz 2003).
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