Approach
Motion sickness may be alleviated by behavioral or pharmacologic measures. Choice of treatment is determined by individual patient characteristics (age, need to perform demanding tasks during motion, sensitivity to medication) and the likely severity and duration of the motion challenge.
For moderate short exposures to provocative motion, such as a short ferry crossing in moderate seas, susceptible individuals may be advised to sit or lie as still as possible. Any necessary movement should be brief. Access to cool air and slow deep breathing may help control mild nausea.[64]
Drugs are used to manage symptoms during occasional experiences of provocative motion.
Prophylactic medication (e.g., promethazine) may be considered for people who are highly susceptible with the caveat that prolonged drowsiness may be a possible adverse effect of medication.
In rare cases of repetitive vomiting, intravenous hydration may be necessary even before a diagnosis has been reached.
Behavioral treatment including desensitization, anxiolytic exercises, and cognitive behavioral therapy, as used for military air crews, is appropriate for personnel such as navy crews who will repeatedly be exposed to provocative motion.
Breathing and behavioral measures
Anxiety enhances motion sickness and is a characteristic of many patients who have visual vertigo and space and motion discomfort. Controlled breathing, also used routinely as an anxiolytic tactic in physical therapy and psychotherapy, has a value in the management of motion sickness.
Studies investigating the value of "control breathing" to ameliorate motion sickness have shown that focusing on breathing regularly and moderately is an effective countermeasure for moderate motion challenges, with about one half to two-thirds the efficacy of the industry standard of scopolamine.[64][65][66][67] Controlled breathing can be difficult. Patients should be advised to try to breathe independently of vehicle motion.[62] Controlled breathing may be practiced whenever any motion challenge is anticipated and may be continued throughout motion or until there appears to be no development of symptoms.
Cool fresh air and avoidance of unpleasant smells or sights are helpful, especially if the patient is traveling with smokers or young children.
Patients with motion sickness often experience symptoms with changes in head and body positions, which raises the possibility of a higher-level dysfunction in sensory integration for spatial orientation and body perception. In this context, activities that can enhance spatial orientation and body coordination (e.g., dancing) can be helpful as a treatment strategy to alleviate symptoms in patients. This is supported by the effect of long-term training in disciplines such as ballet dancing and yoga.[68][69]
Pharmacotherapy
Drugs are used in the management of motion sickness for occasional motion exposures such as an isolated airplane flight or boat ride. Many different formulations and types of drugs have been studied and used. There is considerable overlap with drugs recommended for dizziness, vertigo, vestibular disease, and motion sickness symptoms.[30] Teenagers and adults should take these only if they are not expected to operate machinery or to function at peak levels of efficiency. They are not indicated for repeated motion exposures, because they impede the advantageous habituating effect of repeated provocative motions. Therefore, although useful for occasional exposures, they are not recommended for repetitive/continual exposure such as a sailing vacation. However, drugs may also be useful if habituation and other behavioral therapies have been tried unsuccessfully. Other factors exacerbating motion sickness (e.g., migraine) may be suspected if habituation is ineffective, so that drug treatment may not be straightforward. Effectiveness would have to be established on an individual patient basis.
Drugs used for motion sickness include antimuscarinics (e.g., scopolamine) and antihistamines (e.g., dimenhydrinate, diphenhydramine, meclizine).[9][70] Other options may include prochlorperazine, metoclopramide, sympathomimetics, and benzodiazepines.[9] Of these, scopolamine is generally accepted as the industry standard.[71] Although its relative effectiveness has rarely been put to direct comparison, much experience with its effectiveness has been gained in the military, where its benefits are widely accepted.[72] However, all of the drugs used for preventing motion sickness are only partially effective.
A Cochrane review found that there is probably a reduction in the risk of developing motion sickness symptoms under naturally occurring conditions of motion when using first-generation antihistamines (e.g., dimenhydrinate) in motion sickness-susceptible adults, compared to placebo. However, the review found that antihistamines may be more likely to cause sedation when compared to placebo and the evidence suggested antihistamines were not effective at treating motion sickness once it has already started.[73]
Antihistamines are generally the first-line choice for children. However, oversedation of young children with antihistamines can be life-threatening, and their use for motion sickness is considered off-label. Some children may experience paradoxical agitation with antihistamines. Scopolamine can cause dangerous adverse effects in children and should not be used.[9]
Oral and transdermal preparations must be taken before travel to achieve effective blood levels. Motion sickness prevents drug absorption due to gastric stasis.[74] Transdermal administration of scopolamine offers the advantage of providing protection for up to 72 hours with low constant concentration levels in blood, consequently reducing adverse effects. Double dosing in resistant individuals is safe and has few adverse effects.[75] There is little interference with performance, but slower reaction times are noted, which may affect demanding tasks.[76]
Despite minimal adverse effects with some preparations, all available medications for motion sickness have the potential to cause drowsiness and an inability to function at a high level of concentration.
Many individuals will become motion sick during severe motion challenges such as a voyage on rough seas, and medication will become the first line of treatment for individuals who are not habituated to motion. Sedation with promethazine may be considered for the most severely affected individuals, but this is indicated only if a high level of functioning is not required.
Fluid replacement
In rare cases of repetitive vomiting, intravenous hydration may be necessary.
Habituation and cognitive behavioral therapy
Habituation is the first line of treatment for patients who will have to undergo frequent motion experiences (e.g., for their occupation).[77] The most effective habituation to motion sickness is repeated brief exposures to the provocative motion in a desensitization regimen. These may be undertaken one or more times daily for several days until almost total immunity has been acquired.[8][9][65][78] Some desensitization may be attained within a motion exposure. Motion sickness induced by exposure to an optokinetic drum was reduced when drum exposure was scheduled for 3 times per week, but no habituation occurred if the drum exposures were only once per week.[79] The beneficial conditioning and desensitization effects of brief exposures to optokinetic training in reducing sea sickness have been reported in one study.[80] Other aspects of habituation include the following.
Motion should be stopped in any individual session if the trainee develops significantly negative symptoms and particularly headache.[8]
Desensitization to one kind of motion does not necessarily generalize to others. For example, a seasoned sailor may readily become motion sick when flying in a light aircraft to which the sailor is unaccustomed.[81]
Effects of desensitization are lost if exposure to the provocative circumstance is not maintained.
The simple principle to be followed is that desensitization should be achieved through frequent exposures of slowly increasing duration, gradually building up to prolonged tolerance of motion.
When motion provokes multiple and disabling symptoms, habituation should be undertaken within the framework of cognitive behavioral therapy and anxiolytic tactics.[82] The treatment of those who are severely affected by motion sickness and develop not only nausea but also secondary symptoms that include headache, disorientation, and severe fatigue requires a systematic multidisciplinary approach, which could be termed "cognitive desensitization anxiolytic lifestyle therapy." The various elements have been adopted from military studies and from treatments developed for patients with vestibular disorders and stress-induced migraine.[82]
Key elements of the process
Appraisal by the patient of all the environmental circumstances that provoke malaise, perhaps with a special focus on nausea and headache, and also of any events or circumstances that offer amelioration or relief. The appraisal should be explicit, perhaps written down or made into a symbolic "map." Progress can be monitored from this appraisal.
Explanation by the therapist of the pathophysiologic background to motion sickness, anxiety, and stress.
Systematic and progressive desensitization to provocative circumstances. This will be conducted at frequent intervals, each involving short exposures. Exposure duration may be increased if the patient progresses well. In practical terms desensitization could be achieved, for example, by frequent short car journeys before undertaking a road trip.
Each exposure will be conducted under full cognitive and verbal control of the patient. The patient will know exactly what to do, under what circumstances to abort, and what tactics to perform to reduce negative feedback.
Anxiety and mild levels of nausea encountered during desensitization can be controlled by postural relaxation, taking "time out," and controlled breathing. These may be assisted with biofeedback.[77][83]
Circumstances under which journeys are undertaken should be controlled where possible. For example, if the patient is subject to stress-induced headache, activities should be controlled in the time before traveling so the patient feels as well as possible. Foods including alcohol, which may lower the threshold for nausea in the individual, should be avoided. Smokers are more resistant to motion sickness when they are deprived of nicotine.
Circumstances that ameliorate malaise (of any kind) should be exploited. For some this may be a sporting activity; for others, it may be relaxing or taking a pleasant walk.
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