Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

anticipated motion sickness

1st line – breathing + behavioral measures

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ACUTE
|
anticipated motion sickness
|
non-severe disease or severe with sedation not acceptable
1st line – 

breathing + behavioral measures

Controlled breathing, also used routinely as an anxiolytic tactic in physical therapy and psychotherapy, has a value in the management of motion sickness.

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 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, natural 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]

Consider – pharmacotherapy

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ACUTE
|
anticipated motion sickness
|
non-severe disease or severe with sedation not acceptable
Consider – 

pharmacotherapy

Treatment recommended for SOME patients in selected patient group

Drugs used for motion sickness include antimuscarinics (e.g., scopolamine) and antihistamines (e.g., dimenhydrinate, diphenhydramine, meclizine).[9][70] Scopolamine is generally accepted as the industry standard.[71]

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. 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.

Drug treatments 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.

Primary options

scopolamine transdermal: children ≥12 years of age and adults: apply 1.5 mg patch at least 4 hours before travel and change every 72 hours when required

More

Secondary options

dimenhydrinate: children 2-5 years of age: 12.5 to 25 mg orally at least 30-60 minutes before travel and repeat every 6-8 hours when required, maximum 75 mg/day; children 6-11 years of age: 25-50 mg orally at least 30-60 minutes before travel and every 6-8 hours when required, maximum 150 mg/day; children ≥12 years of age and adults: 50-100 mg orally at least 30-60 minutes before travel and every 4-6 hours when required, maximum 600 mg/day

OR

diphenhydramine: children 2-5 years of age: 6.25 mg orally at least 30 minutes before travel and repeat every 4-6 hours when required, maximum 37.5 mg/day; children 6-11 years of age: 12.5 to 25 mg orally at least 30 minutes before travel and every 4-6 hours when required, maximum 150 mg/day; children ≥12 years of age and adults: 25-50 mg orally at least 30 minutes before travel and every 4-6 hours when required, maximum 300 mg/day

OR

meclizine: children ≥12 years of age and adults: 25-50 mg orally at least 60 minutes before travel and repeat every 24 hours when required

1st line – breathing + behavioral measures

Back
ACUTE
|
anticipated motion sickness
|
severe disease (sedation acceptable)
1st line – 

breathing + behavioral measures

Controlled breathing, also used routinely as an anxiolytic tactic in physical therapy and psychotherapy, has a value in the management of motion sickness. The patient should try to breathe independently of the vehicle motion.[62] Controlled breathing may be practiced whenever any motion challenge is anticipated and may be exercised 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 traveling with smokers or 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, natural 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]

Consider – promethazine

Back
ACUTE
|
anticipated motion sickness
|
severe disease (sedation acceptable)
Consider – 

promethazine

Treatment recommended for SOME patients in selected patient group

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.

Intramuscular injection sedates for 24 hours in severe cases. Patient will be unable to undertake significant activity. Adverse effects are more likely in children and older people.

Primary options

promethazine: children ≥2 years of age: 0.5 mg/kg (maximum 25 mg/dose) orally at least 1 hour before travel and every 12 hours when required, or 0.5 to 1 mg/kg (maximum 50 mg/dose) intramuscularly at least 1 hour before travel and every 4-6 hours when required; adults: 25 mg orally at least 1 hour before travel and every 8-12 hours when required, or 25-50 mg intramuscularly at least 1 hour before travel and every 4-6 hours when required

unanticipated motion sickness

1st line – breathing + behavioral measures

Back
ACUTE
|
unanticipated motion sickness
1st line – 

breathing + behavioral measures

Controlled breathing, also used routinely as an anxiolytic tactic in physical therapy and psychotherapy, has a value in the management of motion sickness. The patient should try to breathe independently of the vehicle motion.[62] Controlled breathing may be practiced whenever any motion challenge is anticipated and may be exercised 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 traveling with smokers or 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, natural 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]

Consider – intravenous hydration

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ACUTE
|
unanticipated motion sickness
Consider – 

intravenous hydration

Treatment recommended for SOME patients in selected patient group

In rare cases of repetitive vomiting, intravenous hydration (for volume depletion) may be necessary even before a diagnosis has been reached.

ONGOING

known susceptibility

1st line – habituation

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ONGOING
|
known susceptibility
1st line – 

habituation

Habituation is the first line of treatment for patients who will have to undergo frequent motion experiences (e.g., for their occupation). The most effective habituation to motion sickness is repeated brief exposures to the provocative motion in a desensitization regimen. The beneficial conditioning and desensitization effects of brief exposures to optokinetic training in reducing sea sickness have been reported in one study.[80]

Consider – cognitive behavioral therapy

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ONGOING
|
known susceptibility
Consider – 

cognitive behavioral therapy

Treatment recommended for SOME patients in selected patient group

When motion provokes enduring polysymptomatic symptoms, habituation should be undertaken within the framework of cognitive behavioral therapy and anxiolytic tactics.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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