Preventing Motion Sickness: Non-Pharmacological Measures and Medication Options including H1-Antihistamines and Transdermal Scopolamine

2023-05-25 23:03:50

If non-pharmacological measures are insufficient, sitting H₁-antihistamines an option as a preventative measure for those prone to motion sickness (motion sickness). They can only be used exceptionally in children: in case of serious complaints when non-medicinal measures are insufficiently effective, and always on trial first. They should not be used in children under 2 years of age. Transdermaal scopolamine (not available in Belgium) is an option for adults on long journeys.
The benefits of these drugs should always be weighed against the unwanted effectsespecially sedation and anticholinergic effects.
Ginger (not available as a specialty, but as a dietary supplement) is sometimes suggested for motion sickness, but the available evidence does not allow any statement about its effectiveness.

Motion sickness (travel sickness) becomes marked by nausea and vomiting, but also dizziness, paleness, sweating, and possibly yawning, headache, loss of concentration and drowsiness may occur.¹ Of susceptibility to motion sickness decreases with regular exposure to situations that provoke motion sickness and decreases with age (highest incidence between 2 and 12 years).¹

This article is an update of our Folia article from May 2019: we follow the NHG treatment guideline “Travel sickness”, and the Cochrane review on H₁antihistamines for motion sickness.

Information and non-pharmacological advice

According to the NHG treatment guideline “Travel sickness”, information and non-pharmacological advice are always preferred over medication, especially in children.¹

Advice include¹:

• choosing the most stable part of the means of transport (in the front of the car (bus), near the wings of the aircraft, in the middle of the aft deck of a boat),
• inform that during long journeys adaptation occurs after a few days,
• orient oneself to the horizon,
• provide fresh air,
• listening to (quiet) music,
• consciously calm breathing,
• chewing gum,
• avoid large meals and alcohol consumption before or during the trip,
• avoid reading, computer games or other screen use.

Medicines for motion sickness

Sitting H₁-antihistamines

Adults

A Cochrane Review (2022) shows that preventive use of sitting H₁-antihistamines reduces the risk of motion sickness by slightly less than half in adults prone to motion sickness (e.g. with a history of motion sickness). The review found evidence for cinnarizine and dimenhydrinate, but no specific sedative H₁antihistamine put forward as the best choice. The Cochrane review found no studies over therapy of motion sickness (so once symptoms have occurred).

Cochrane review: Only 3 placebo-controlled studies in adults (n = 240) were considered suitable for inclusion. They investigated cinnarizine or dimenhydrinate. Percentage of patients who no developed symptoms: 25% (placebo) versus 40% (antihistamines). Risk ratio (RR) = 1.81 (95% CI of 1.23 to 2.66), 3 studies (each sea voyage), 240 participants, moderate-certainty evidence.

The NHG treatment guideline “Travel sickness” recommends sedating H₁– reserve antihistamines for the prevention or treatment of motion sickness for relatively serious, persistent complaints if non-pharmacological advice does not help sufficiently. Cinnarizine, meclozine and cyclizine are put forward as the best choices because they are only “mild to moderate” sedative.

In Belgium the “motion sickness” indication is displayed in the GDP listed for the specialties based on cinnarizine, dimenhydrinate in meclozine. The fixed association of cinnarizine + dimenhydrinate (Arlevertan®) has not been studied in motion sickness (source: SKP). Cyclizine (listed as an option in the NHG treatment guideline) is not available as a specialty in Belgium, but the raw material cyclizine HCl is available for pharmaceutical preparation. See the table for details on dosing in motion sickness prevention.

Children

A Cochrane review² finds no studies about using H₁antihistamines in children for the prevention or treatment of motion sickness.

The NHG treatment guideline “Travel sickness” recommends sedating H₁-antihistamines to prevent or treat motion sickness not in children (no evidence of efficacy and there are the unwanted effects). Only for relatively serious and persistent complaints if non-pharmacological advice is not sufficienta trial treatment with sedative H₁antihistamines should be considered. Sedating H₁antihistamines are allowed not used in children under 2 years of age.

See the table for details on dosing in motion sickness prevention.

Safety

The usefulness of sedative H₁antihistamines are often limited by their anticholinerge in sedative effects. They can impair driving ability.
See Repertory Inl.6.2.3. for information on anticholinergic adverse effects.
A Cochrane review² found an incidence of sedation (in adults) of 66% with antihistamines and 44% with placebo. From the in the table mentioned sedative H₁antihistamines, dimenhydrinate appears to be the most sedative.
The sedative and anticholinergic effects are enhanced when taking other drugs with a sedative (including alcohol!) or anticholinergic effect.

Cinnarizine can in rare cases extrapyramidal symptoms provoke, sometimes associated with feelings of depression.

Children and the elderly are more sensitive to the unwanted effects of the H₁-antihistamines. Sedating H₁antihistamines can cause paradoxical stimulation in children and the elderly, including insomnia and nervousness. They should definitely be avoided in children under two years of age.¹

Pregnancy and breastfeeding

Pregnancy. There are no clues That H₁-antihistamines increase the risk of birth defects, miscarriage, premature births or low birth weight. For cyclizine, dimenhydrinate and meclozine the data are numerous, for cinnarizine the data are limited (Lareb, LeCrat, Briggs). In the neonate, sedation may occur if sedating H₁antihistamines are administered at the end of pregnancy. Lareb states that meclozine can be expected to be used safely in motion sickness at doses such as those used for morning sickness.

Breastfeeding. The data is very limited. The possibility of sedation in the infant as well as agitation, poor drinking and dry mouth should be considered (LarebLeCrat). LeCrat sees no problem with a single intake, but recommends interrupting breastfeeding with repeated intake. Lareb states that meclozine or cinnarizine are not strong sedatives.

Table. Dosage for prevention of motion sickness (source: SKP, except for cyclizine for which BNF and BNF for children were used)

	Operating time	Time of administration	Dosage adults	Dosage cheek Note: not recommended in principle, only in exceptional cases in children older than 2 years with serious complaints and always on trial first
Cinnarizine: Stugeron® tabl. (deelb.) 25 mg	6 hours	at least ½ hour before departure	1 tablet	to be used from the age of 6 years 6-12 years: ½ tablet from 13 years: 1 tablet
Dimenhydrinate: R Calm Dimenhydrinate® tabl. (deelb. in 4) 50 mg	4 hours	1 hour before departure	1 tablet, max. 4 tablets/24 hours	to be used from the age of 2 years 2-8 years: ¼ tablet (max. 1 tablet/24 ​​hours) 8-12 years: ½ tablet (max. 2 tablets/24 hours) from 13 years: 1 tablet, max. 4 tablets/24 hours
Meclozine: Agyrax® tabl. (deelb.) 25 mg	24 hours	1 hour before departure	1 to 2 tablets	to be used from the age of 13 years
Cyclizine HCl (magisterial)	8 o’clock	1 to 2 hours before departure	50 mg	to be used from the age of 6 years 6-11 years: 25mg from 12 years: 50 mg

Scopolamine in transdermal patch

A Cochrane review (2011)³ shows that preventive use of transdermal scopolamine reduces the risk of motion sickness by about half in adults. The Cochrane review found no studies over therapy of motion sickness in adults (i.e. once symptoms have occurred), nor studies on prevention or treatment of motion sickness in children.

Cochrane review: transdermal scopolamine was more effective than placebo in preventing symptoms of motion sickness (nausea) in adults. Risk ratio (RR) = 0.48 (95% CI of 0.32 to 0.73), 5 studies (mostly seasickness), 165 participants, studies of variable quality.

The NHG treatment guideline “Travel sickness” states that transdermal administration of scopolamine can be considered as a long-term prevention of motion sickness (e.g. for several days during a sea voyage) in an adult necessary.

In Belgium are transdermal patches based on scopolamine not available. They have been commercialized abroad for use from the age of 18 (eg Scopoderm TTS® in the Netherlands and France). The plaster can be introduced [zie Repertorium > Inl.2.2.12.].

The dosage in adults is 1 patch (containing 1.5 mg scopolamine), applied behind the ear 6 to 15 hours before departure. Remove the patch after a maximum of 72 hours and, if necessary, apply a new patch behind the other ear.​

Sedation in anticholinergic unwanted effects (see Repertory Inl.6.2.3.). pronounced. It can impair driving ability. There is a risk of confusion and hallucinations, especially in the elderly. The sedative and anticholinergic effects are enhanced when taking other drugs with a sedative (including alcohol!) or anticholinergic effect.
Data on the use of scopolamine patches during the pregnancy of de period of breastfeeding are very limited or absent, and a good risk assessment is not possible (Lareb).

Ginger

Ginger-based preparations are sometimes suggested for motion sickness.

In Belgium, ginger is not available as a medicine, but as a dietary supplement.

The NHG treatment guideline “Travel sickness” states that there insufficient evidence is to recommend ginger or ginger root in tablet or capsule form or as a powder for motion sickness. The studies on ginger in motion sickness are of low quality and their results are inconclusive.

Not working with motion sickness

• Non-sedating antihistamines very few pass through the blood-brain barrier and do not appear to be effective in motion sickness (Martindale).¹ De Cochrane review² found no studies on prevention and treatment of motion sickness with non-sedating H₁-antihistamines.

• Metoclopramide, domperidone in 5HT₃-antagonists are not effective for motion sickness (Martindale).

Specialty Names

Specific resources

1 De Jong J and Verdijn MM. NHG Treatment Guideline “Travel Sickness”. Published: April 2017; last update: April 2017.
2 Karrim N, Byrne R, Magula N, Saman Y. Antihistamines for motion sickness. Cochrane Database of Systematic Reviews 2022, Issue 10. Art. No.: CD012715. DOI: 10.1002/14651858.CD012715.pub2.
3 Spinks_A, Wasiak_J. Scopolamine (hyoscine) for preventing and treating motion sickness. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD002851. DOI: 10.1002/14651858.CD002851.pub4.

General Resources

Martindale – The Complete Drug Reference. Nausea and vomiting (Gastrointestinal Drugs – Management of Gastrointestinal Disorders) > Motion sickness. Electronic version (last consulted on 27/04/23)