Highlights & Basics
- Motion sickness is a common condition provoked by transportation or visual motion.
- Characterized by nausea/vomiting, possibly accompanied by other symptoms such as dizziness or headache.
- Controlled breathing is helpful during episodes.
- Drug therapy includes antimuscarinics and antihistamines; however both may have significant adverse effects (notably drowsiness) and impede habituation (desensitization).
- Habituation and cognitive behavioral therapy may be useful for people who must undergo repeated provocative motion (e.g., for their occupations).
Quick Reference
History & Exam
Key Factors
epigastric discomfort
nausea
headache
vomiting
Other Factors
cold sweating
dry mouth
dizziness
yawning and sleepiness
pallor
recent alcohol consumption
unsteadiness and incoordination
Diagnostics Tests
1st Tests to Order
clinical diagnosis
Treatment Options
acute
anticipated motion sickness
non-severe disease or severe with sedation not acceptable
severe disease (sedation acceptable)
unanticipated motion sickness
breathing + behavioral measures
intravenous hydration
Definition
Classifications
Vignette
Common Vignette 1
Common Vignette 2
Other Presentations
Epidemiology
Etiology
- Analyses of motions that provoke motion sickness, together with experiments involving motion simulation, reveal that sickness occurs most readily with mechanical motions circa 0.2 Hz (cycles per second) and declines with frequencies of motion above and below.
- Modern large ocean liners, whose movements involve very low frequencies, are not particularly nauseogenic; similarly, riding in a ski boat or riding a horse, both of which involve high mechanical frequencies, may induce fear and discomfort but are not particularly nauseogenic.
- In contrast, the mechanically smooth movements of a car, a tilting train (high-speed train with a tilting mechanism to increase speed on curved railway tracks [e.g., Acela Express from Washington, DC to Boston]), or a medium-sized boat, all of which involve frequencies of motion about 0.2 Hz, readily provoke motion sickness.
- The frequency of motion sickness is also determined by the intensity of motion, so that even with a frequency much lower or higher than 0.2 Hz, sickness will occur if motion is sufficiently vigorous.
- Experiences of simulated visual motion can cause dizziness, nausea, and vomiting.
- Nauseogenic visual experiences include virtual reality displays, movies, computer animations, and even television.[19] In addition to inducing sensations of self-motion and nausea, modern computerized displays also induce disorientation with consequential loss of performance, a condition that has been termed "cybersickness."
- The kinds of symptoms provoked by visual motion differ somewhat from those experienced with true self-motion. The most significant symptom provoked by visual flow is possibly headache, and it has been suggested that pathophysiologic mechanisms similar to those responsible for migrainous phenomena may be involved.[20] [21] The illusion of motion stimulated by an optokinetic drum elicits the full range of motion sickness symptoms, including nausea.[22]
- The development of motion sickness and intensity of symptoms may be exacerbated by activities such as reading.
- There are several factors involved. At a mechanical level, body and particularly head movements within a vehicle may simply increase the intensity of provocative motion stimuli. A particularly important factor is movement of the head within the framework of the vehicle, which is itself moving, such as a car turning a corner. These may provoke unusual and intense stimulation of the three-dimensional, semicircular canals and otolith organs of the labyrinth, which imparts intense dizziness and false perceptions of self-motion.[2]
- Physiologic factors enhancing motion sickness usually involve a conflict between sensory inputs. The classic case is trying to read in a moving car: the vestibular ocular reflexes, which stabilize the eyes on external stationary objects, must be suppressed by visually guided eye movements in order to maintain scanning fixation on the text that is moving with the protagonist. A similar conflict arises in high-speed tilting trains (or an airplane making a coordinated turn when it comes in to land or takes off), which are particularly nauseogenic if the passenger, who feels completely upright in the cabin, sees the external landscape appearing to swing dramatically up and down.[23]
Pathophysiology
- Vehicle motions that provoke motion sickness almost always challenge how people sense, perceive, or respond to verticality. For prolonged accelerations of low-frequency content the body is preferentially perceived as tilted; for example, when taking off on an aircraft, one feels tilted backward before the nose wheel actually lifts off the tarmac. For rapid to-and-fro motion of high-frequency content such as rocking on a train, the preferential perception is of oscillatory translation. In parallel with perception, the vestibular-reflex eye movements evoked by low-frequency motion are a counter-rolling of the eyes, appropriate for tilting the head, whereas the response to high-frequency head movement is lateral eye movements, which compensate for the head movement to help fixate on stationary objects.
- It is generally proposed that the decision to interpret movement as tilt or translation is served, in part, by frequency filtering vestibular signals so that low frequencies are interpreted to signify tilt. The frequency tuning of nauseogenic motion about 0.2 Hz spans the transition between preferential interpretations of motion as tilt or translation.[34] [35] [36] [37] In this zone of ambiguity the brain is uncertain of how to interpret sensory input, and perceptual conflicts may exist between vestibular processing and the behavioral context. Thus, a key element in the nauseogenic process is the development of an internal conflict in the processing of spatial orientation.[2]
- An important example of conflict is "visual-vestibular," typified by attempting to read in a car, which makes many people motion sick. The vestibular ocular reflexes, which stabilize the eyes on the stationary external environment, are in conflict with visual fixation on the text, which is moving with the protagonist.
- A possible explanation of the frequency separation of tilt-translation is that the constraints of body mechanics determine that the body must tilt for high-speed low-frequency maneuvers, whereas the trunk and legs are thrust from side to side during high-frequency maneuvers. These distinct tactics are apparently at work in many activities, such as running, cycling, or skiing. However, the transition from low- to high-frequency movements is a difficult tactic.
- "Toxin theory:" the internal conflicting sensory or perceptual states resulting from certain kinds of motion are similar to the consequences of ingesting a neurotoxin, which the body expels by vomiting. As a corollary the vestibules have evolved for the 2-fold purpose of transducing head orientation and sensitivity to ingested toxins.[38] [39]
- Hemodynamic redistribution: vomiting relieves the stomach of digestive function so that blood can be directed to muscle activity to help the protagonist resolve the motion challenge.
- Anxiety: initial symptoms of nausea alert the person to the distressing situation and, as with other severe anxiety states, can lead to vomiting.
Diagnostic Approach
Symptoms
- Headache
- Dizziness/light-headededness/unsteadiness
- Epigastric discomfort
- Vomiting or retching
- Cold sweats
- Dry mouth
- Feeling of eye strain
- Sleepiness
- Sweating
- Anorexia
- Apathy
- Warm sensation
- Generalized discomfort
- Excessive salivation
- Increased sensitivity to odors
- Loss of appetite
- Hyperventilation.
Establishing context
History
- Childhood age (2-12 years)
- Female sex
- Family history of motion sickness
- History of migraine
- Vestibulopathy
- Spatial disorientation and space-motion discomfort
- Unpleasant odors or visual stimuli
- Conflicting sensory inputs (e.g., reading in car, tilting trains)
- Psychological factors (e.g., anxiety)
- Undertaking spatially loaded concurrent tasks such as looking at a map.
- Food poisoning or other gastric disturbance
- Migraine
- Inner ear disease.
- Dizziness or vertigo
- Pain
- Hearing loss
- Tinnitus
- Visual disturbance.
Tests
Risk Factors
History & Exam
Tests
Differential Diagnosis
Migraine attack
Differentiating Signs/Symptoms
- May be indistinguishable clinically.
- Presence of migraine may cause motion sickness to develop more rapidly in the appropriate setting.
- Migraine may be accompanied by aura and usually persists for hours beyond the motion exposure.
Differentiating Tests
- There are no laboratory tests for differential diagnosis. Head imaging may exclude alternative diagnoses.
Food poisoning
Differentiating Signs/Symptoms
- Travel history or ingestion of high-risk foods may suggest food poisoning.
- The acute phase of food poisoning is less likely to be associated closely with motion provocation and may persist after motion.
- A combination of nausea and diarrhea with severe stomach cramps is more likely with food poisoning.
Differentiating Tests
- May identify etiologic agents from fecal samples.
Acute vestibular disorder
Differentiating Signs/Symptoms
- Dizziness (in the form of rotatory vertigo) with nystagmus and gait ataxia will be dominant features that accompany nausea and vomiting.
Differentiating Tests
- Investigations such as audiology or MRI of the head may exclude specific pathologies.
Screening
Specific occupations
Treatment Approach
- 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.[57]
- 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
Pharmacotherapy
Fluid replacement
Habituation and cognitive behavioral therapy
- 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.[72]
- Effects of desensitization are lost if exposure to the provocative circumstance is not maintained.
- 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.
- 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.
Treatment Options
anticipated motion sickness
non-severe disease or severe with sedation not acceptable
breathing + behavioral measures
Comments
- 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.[54] 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.
pharmacotherapy
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
- scopolamine transdermal
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
- dimenhydrinate
- 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
- diphenhydramine
- 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
- meclizine
Comments
- 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.[64]
- 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.
severe disease (sedation acceptable)
breathing + behavioral measures
Comments
- 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.[54] 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.
promethazine
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
- promethazine
Comments
- 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.
unanticipated motion sickness
breathing + behavioral measures
Comments
- 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.[54] 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.
intravenous hydration
Comments
- In rare cases of repetitive vomiting, intravenous hydration (for volume depletion) may be necessary even before a diagnosis has been reached.
known susceptibility
habituation
Comments
- 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.[71]
cognitive behavioral therapy
Comments
- When motion provokes enduring polysymptomatic symptoms, habituation should be undertaken within the framework of cognitive behavioral therapy and anxiolytic tactics.
Emerging Tx
Dextroamphetamine
5-HT1 agonists (triptans)
Intranasal scopolamine
Acupressure
Prevention
Primary Prevention
- In cars the driver should drive slowly and smoothly. The person susceptible to motion sickness should be in the front seat, be well restrained in the vehicle, not make head movements, and fix eyes on the horizon. Activities in the car such as reading should be avoided, as they create a conflict between vestibular reflexes working to stabilize the eyes on the external environment and visual reflexes tracking the text. Such sensory conflicts provoke and enhance motion sickness.
- On ships and in trains, most benefit is obtained from sitting toward the front for a train and approximately in the middle for a ship.[10] A position near the center of rotations in a ship/boat minimizes the vertical, linear components of motion.
- A view of the road ahead or of the horizon may help to prevent motion sickness in some individuals, whereas others fare better with eyes closed. For ship travel a position below deck lends greater susceptibility to becoming seasick in some people, whereas others may find greater relief from lying down, eyes closed. The individual traveler should determine the best tactic (eyes open or eyes closed; view the interior or the forward horizon).[10] [20] [51]
- In high-speed tilting trains, motion sickness can largely be avoided by obscuring the view out of the window to the tilting landscape.[23]
- In airplanes, motion sickness becomes significant during turbulence or landing and takeoff. The view out of the cabin window showing that the plane is tilting significantly and any head movements made during the maneuvering that provoke unusual vestibular stimulation can be highly nauseogenic. A susceptible passenger should sit still and close their eyes.
- During turbulence the unpleasant visceral sensation provoked by the plane suddenly losing height can be minimized by tightening the seatbelt across the hips, bracing the body against a seat with the arms and legs, contracting ventral muscles of the torso, and focusing on controlling breathing so that it is regular and kept at moderate depth. Pressing the P6 acupuncture site (found between the tendons of the palmaris longus and flexor carpi radialis muscles, 3 patient finger breadths away from the flexor crease on the wrist) may help some patients.[52] [53]
- Focusing on controlling breathing at a regular rate of moderate depth will help prevent the development of motion sickness and alleviate symptoms. Respiratory cycles naturally entrain with periodic motion, such as on a ship. Deliberately desynchronizing breathing with the vehicle motion will provide greatest benefit.[54]
- Being in control of the vehicle (e.g., driver, pilot, helmsman) rather than a passive passenger gives significant protection against motion sickness. Patients should be in control of the vehicle, if at all possible. In addition, passengers with a view of the road are less likely to have symptoms compared with those who do not.[11]
- Other behavioral techniques to prevent or reduce motion sickness include staying hydrated; limiting alcohol and caffeine intake; eating small, frequent meals; avoiding smoking; and using distractions (e.g., controlled breathing, music, aromatherapy, flavored lozenges).[9]
Secondary Prevention
Follow-Up Overview
Prognosis
Monitoring
Complications
Citations
Centers for Disease Control and Prevention. CDC Yellow Book 2024: health information for international travel. Section 8: Travel by air, land & sea - motion sickness. May 2023 [internet publication]. [Full Text]
Spinks AB, Wasiak J. Scopolamine (hyoscine) for preventing and treating motion sickness. Cochrane Database Syst Rev. 2011;(6):CD002851.[Abstract][Full Text]
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Key Articles
Referenced Articles
Guidelines
Treatment
Summary
Guidelines on the management of motion sickness, including tips for prevention.Published by
Centers for Disease Control and Prevention
Published
2023