Ross Hauser, MD.
Cyclic vomiting syndrome is characterized by recurrent episodes of severe nausea and vomiting separated by symptom-free intervals. Episodes can last for hours to days and are often associated with migraine, autonomic dysfunction, anxiety, and stress. Despite ongoing research, the exact cause of cyclic vomiting syndrome remains unknown.
Is the cause of cyclic vomiting syndrome in the neck?
When we see patients with problems of cervical spine instability, they usually present with many symptoms, not just one. These symptoms are not confined to neck pain, arm numbness, headaches, or the traditional symptoms of cervical spine instability or cervical radiculopathy, some of these symptoms these people describe can seem remote or unrelated to their neck problems, but they are not. These symptoms patients may discuss with us are the constant presence of nausea and/or gastroparesis or a problem with their stomach’s ability to empty itself of food. While many readers may not be familiar with the term gastroparesis, they are familiar with the symptoms they suffer from heartburn, vomiting, the sensation of being bloated, a constantly full stomach, and of course nausea.
Pressure or impingement on the vagus nerve, the nerve involved in regulating stomach emptying, nausea, intestinal movement, and the vomiting reflex. Cervical ligament instability may impact vagal function.
We want to stress that nausea and digestive problems can be caused by many problems, however, many patients we see have nausea caused by cervical vertigo and cervicogenic dizziness and may have underlying problems with cervical instability and beyond. This includes compression of the brain stem
- In our article, Upper Cervical Instability and Compression of the Brainstem, we point out that the nausea center is right in the lower part of the brainstem. This causes many people to feel nauseated all the time and nobody can tell what’s causing it. These people have a history of seeing gastroenterologists and various gastrointestinal doctors and they would have no idea that the cause of this chronic nausea can be upper cervical instability.
- In some patients we see, we can trace their digestive problems to compression of the vagus nerve, which will be discussed below. In our article Cervical spine instability as a cause of your digestive disorders, we present the case of a particular patient, who over the course of years developed many symptoms that led her to many specialists including, gastroenterologists, ENTs, neurologists, pain doctors, etc. She has had the gradual onset of ringing in the ears, tinnitus, migraines, fainting spells, loss of balance, speech issues, voice issues, and interesting to me is GERD or gastroesophageal reflux disease and other digestive problems.
Initially cyclic vomiting syndrome was thought to occur only in children
Initially cyclic vomiting syndrome was thought to occur only in children. However researchers began to recognize that cyclic vomiting syndrome was occurring in adults in more numbers than thought. The adult form of cyclic vomiting syndrome was discussed in an April 2008 paper in the journal Neurogastroenterology and motility (1). Then researchers began to suspect a neck component may be at the root cause of the vomiting problem in some patients.
In a 2014 study published in the journal Experimental brain research (2) wrote that many associated factors that predict Cyclic vomiting syndrome attacks, such as prolonged periods of fasting, sleep deprivation, physical and emotional stress, or acute anxiety, implicate sympathetic nervous system activation as a mechanism that may contribute to Cyclic vomiting syndrome pathogenesis.
My note here: Dysfunction of the sympathetic nervous system and its activation is one of the hallmark problems of cervical spine instability in many patients.
Two articles on our site discuss this further:
Understanding symptoms from the sympathetic nervous system and parasympathetic nervous system
Returning to the 2014 paper, the researchers “set forth a conceptual model in which Cyclic vomiting syndrome is viewed as a brain disorder involving maladaptive plasticity (the brain is getting and delivering harmful messages and telling the body to react in a way that is not based in reality. For example over sensitivity to senses or pain). within central neural circuits important for allostatic regulation of the sympathetic nervous system. Treatment recommendations called for “cognitive behavioral therapy, stress management (“mind-body”) interventions, regular exercise, improved sleep, and avoidance of cannabis and opiate use.”
A January 2010 case history (3) in the Journal of general internal medicine report the case of a 47-year-old man with recurrent episodes of intractable nausea and vomiting for one year. His symptoms persisted for 4-7 days and then resolved spontaneously, only to return after periods of time ranging from one week up to a month. After an extensive workup, which failed to determine any causative explanation for his symptoms, he was diagnosed with cyclic vomiting syndrome. His episodes of vomiting were successfully terminated with the use of intranasal sumatriptan (medicine typically used for migraine).
A February 2025 study (4) lead by researchers at the Harvard Medical School suggested people with Cyclic vomiting syndrome showed abnormal autonomic nervous system function and increased sensitivity to pain compared with healthy adults. During painful stimulation, they had reduced vagal (parasympathetic) activity, altered brain responses in regions that control pain and body awareness, and pain that became more intense over time. These findings suggest that Cyclic vomiting syndrome involves disrupted brain-gut communication and autonomic nervous system dysfunction.
A September 2024 review to the American Gastroenterological Association (AGA) Institute Clinical Practice Update (5) wrote: “Several conditions are associated with adult cyclic vomiting syndrome, the most common of which are mood disorders, including anxiety, depression, and panic disorder (collectively present in 50%–60% of patients). A quite notable proportion of adult patients with cyclic vomiting syndrome experience migraine (present in 20%–30%) or even seizure disorders (approximately 3%), which suggests some common pathophysiological mechanism that operates across episodic conditions.
There is emerging appreciation that autonomic imbalances, including postural orthostatic tachycardia syndrome, are observed in a substantial subgroup of patients with cyclic vomiting syndrome and may relate to its underlying pathophysiologic mechanisms.
In our opinion, underlying pathophysiologic mechanisms can be related to the vagus nerve.
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References
1 Abell TL, Adams KA, Boles RG, Bousvaros A, Chong SK, Fleisher DR, Hasler WL, Hyman PE, Issenman RM, Li BU, Linder SL. Cyclic vomiting syndrome in adults. Neurogastroenterology & Motility. 2008 Apr;20(4):269-84. [Google Scholar]
2 Levinthal DJ, Bielefeldt K. Adult cyclical vomiting syndrome: a disorder of allostatic regulation?. Experimental brain research. 2014 Aug;232(8):2541-7. [Google Scholar]
3 Kowalczyk M, Parkman H, Ward L. Adult cyclic vomiting syndrome successfully treated with intranasal sumatriptan. Journal of General Internal Medicine. 2009 Nov 13;25(1):88-91. [Google Scholar]
4 Bolender A, Staley R, Garcia RG, Barbieri R, Andronesi O, Castel S, Thurler A, Napadow V, Kuo B, Sclocco R. Altered parasympathetic outflow and central sensitization response to continuous pain in cyclic vomiting syndrome: a functional magnetic resonance imaging study. American Journal of Physiology-Gastrointestinal and Liver Physiology. 2025 Feb 5. [Google Scholar]
5 Levinthal DJ, Staller K, Venkatesan T. AGA Clinical Practice Update on Diagnosis and Management of Cyclic Vomiting Syndrome: Commentary. Gastroenterology. 2024 Jul 16;167(4):804-11. [Google Scholar]