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GUIDELINE: Violent Vomiting Rates Rising! Can you Clinch the Cause (& Major Mimickers)?

  • The Review Course in Family Medicine
  • Jul 23
  • 2 min read

A man holding up a glass of whisky

Did you guess the cause from the title? Or perhaps even from the sound of a patient suffering from this?


Emergency room and urgent care clinicians have undoubtedly encountered this situation that can be relentless and uncomfortable for patients. But if your practice is mostly outpatient care, perhaps you haven’t seen it as often.


That being said, those of us who work in primary care also play a key role in prevention of the emetic phase.


Here are some top takeaways from the AGA guideline on…you guessed it, Cannabinoid Hyperemesis Syndrome:


  1. It’s different than Cyclic Vomiting Syndrome (CVS)


Just because the patient uses cannabis it might not be the cause so consider CVS, though that is challenging as CVS is a rule-out diagnosis meaning no other cause can be contributing. Some more key differentials include:


- Rumination Syndrome

- Gastroparesis (do they have diabetes?)

- Pregnancy (BETAAA!)

- Migraine



  1. ACUTE treatments include


- Antipsychotics commonly used for nausea e.g. haloperidol, olanzapine

- Intravenous fluids

- Topical capsaicin

- Benzodiazepines

- Antihistamine (promethazine)

- Ondansetron



  1. LONG-TERM treatment:

Between acute episodes or when your patient sees you for follow-up after their ER visit for this, consider helping them with:

- Stop the cannabis

- Tricyclic antidepressants

- Note “cold turkey” can cause withdrawal and recurrence


Other treatments are being investigated with limited evidence so far.


Here are the proposed diagnostic criteria (Rome IV):


1. Criteria fulfilled for at minimum three months, with symptomatic onset occurring at least six months before diagnosis

2. Stereotypical episodic vomiting resembling cyclical vomiting syndrome in onset, duration, and frequency

3. Presentation after prolonged, excessive cannabis use

4. Relief of vomiting by a sustained cessation of cannabis use

5. May be associated with “pathologic” bathing behavior, e.g., prolonged hot baths and showers.



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