Dramatic Response to Nebivolol in an Adult Case of Cyclic Vomiting Syndrome

Cyclic vomiting syndrome (CVS) is an episodic syndrome associated with migraine, characterized by stereotypical attacks of intense nausea and vomiting, recurring with a predictable periodicity. Preventive treatment should be considered if attacks are frequent and refractory to attack treatment. Retrospective studies showed benefit using tricyclic antidepressants, antiepileptics (zonisamide, levetiracetam, topiramate), or β-blockers (propranolol). In adult, no controlled trials are available. A case report showed efficacy of nebivolol in addition to amitriptyline in an 18-year-old girl with CVS. We report for the first time a near-resolution of adult CVS with nebivolol in monotherapy. A 58-year-old woman with a history of thyroid carcinoma and hepatic metastasis treated 10 years ago reported episodes of intense nausea and vomiting, from the age of 40. She had no personal history of migraine but her brother had migraine. The attacks were stereotypical, with a predictable periodicity, from 6 months during the first years to 1 month for the last 3 years. Without any apparent reason, the episodes were more frequent in the months previous her admission at headache center (2 attacks per month). The attacks began during sleep at night, typically on the weekend, with a mean duration of 48 hours. During prodromal phase (previous day), she reported intense tiredness. Concentration difficulties, photophobia and vertigo were also reported during emetic phase. No headache was reported. The resolution was complete between episodes. A brain MRI was normal. Digestive investigations (abdominal computed tomography scan, upper gastrointestinal endoscopy, colonoscopy) didn’t show any lesion responsible for CVS. The high intensity of vomiting was responsible for multiple hospitalizations with intravenous hydration. Antiemetics or sumatriptan were ineffective as attack treatment. An association with Amitriptyline (5 mg/day), coenzyme Q10 and L-carnitine during 2 months was not effective on attack frequency. Higher dosage of amitriptyline was not tolerated. Propranolol (10 mg/day) was tried during 6 weeks but was not tolerated. Two CVS attacks Headache doi: 10.1111/head.13619 © 2019 American Headache Society Published by Wiley Periodicals, Inc. ISSN 0017-8748