Nausea and vomiting

A Strong scientific evidence

• Acupressure, shiatsu : Shiatsu technique involves finger pressure at acupoints and along body meridians. It can incorporate palm pressure, stretching, massaging, and other manual techniques. Numerous scientific studies support the use of wrist acupressure at the P6 acupoint (also known as Neiguan) in the prevention and treatment of nausea after surgery, intra-operative nausea (during spinal anesthesia), nausea from chemotherapy, as well as pregnancy related nausea/vomiting and morning sickness. However, results from studies are conflicting. Effects have been noted in children as well as adults. Better quality research is needed.
• Acupressure appears to be safe if self-administered or administered by an experienced therapist. Serious, long-term complications have not been reported, according to available scientific data. Hand nerve injury and herpes zoster ("shingles") cases have been reported after shiatsu massage. Forceful acupressure may cause bruising.

B Good scientific evidence

• Acupuncture : The practice of acupuncture originated in China 5,000 years ago. Today, acupuncture is widely used throughout the world and is one of the main pillars of traditional Chinese medicine (TCM). Evidence from several small studies supports the use of acupuncture at a specific point on the wrist (P6) to help with chemotherapy-induced nausea. Evidence also supports acupuncture at the wrist P6 point for the relief of post-operative nausea and vomiting in adults.
• Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, neurological disorders, or if taking anticoagulants. Avoid on areas that have received radiation therapy and during pregnancy. Avoid electroacupuncture with irregular heartbeat or in patients with pacemakers. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with a history of seizures.
• Acustimulation : Acustimulation is the mild electrical stimulation of acupuncture points to control symptoms such as nausea and vomiting. A low-intensity electrical current is used to penetrate just slightly below the surface of the skin. There is evidence from small but well-designed studies of seasickness and artificially-induced motion sickness (using laboratory equipment) indicating that acustimulation can reduce symptoms of nausea and vomiting. It may slow down, but not necessarily prevent, the development of motion sickness.
• There is good evidence that wearing the ReliefBand® helps reduce post-operative nausea and vomiting. The effect may be comparable to anti-nausea medications (dimenhyrinate) and may be enhanced when combined with medication. The ReliefBand® is worn like a wristwatch on the inside of the wrist. It stimulates the nerves in the wrist with gentle electrical signals, which are believed to interfere with nausea-inducing messages between the brain and the stomach.
• Avoid if the cause of medical symptoms is unknown. Acustimulation devices may cause slight skin irritation under the electrodes when the wristband is used. Switch wrists to avoid. Acustimulation devices should only be used on the designated area. Use cautiously with pacemakers. Keep acustimulation devices out of the reach of children.
• Ginger : Preliminary studies suggest that ginger (Zingiber officinale) may be safe and effective for nausea and vomiting in pregnancy when used at recommended doses for short periods of time (less than five days). Some publications discourage large doses of ginger during pregnancy due to concerns about mutations or abortion. Additional research is needed to determine the safety and effectiveness of ginger during pregnancy.
• Avoid if allergic to ginger or other members of the Zingiberaceae family (like red ginger, Alpinia purpurata, shell ginger, Alpinia zeru, green cardamom, and balsam of Peru). Avoid with anticoagulation therapy. Avoid large quantities of fresh cut ginger with inflammatory bowel disease or with a history of intestinal obstruction. Use cautiously before surgery or with gastric or duodenal ulcers, gallstones, heart disease, or diabetes. Use cautiously long-term. Use cautiously in underweight patients. Use cautiously if taking heart medications or sedatives and if driving or operating heavy machinery. Use cautiously if pregnant or breastfeeding.
• Music therapy : Music is used to influence physical, emotional, cognitive, and social well-being and improve the quality of life for healthy people, as well as those who are disabled or ill. It may involve either listening to or performing music, with or without the presence of a music therapist. Music therapy helps in a wide range of pain conditions, primarily by its ability to improve mood, encourage relaxation, and elevate pain threshold. Music therapy may reduce nausea and vomiting in bone marrow transplant patients during the preparatory period when they are receiving high-dose chemotherapy with cyclophosphamide (Cytoxan®).
• Music therapy is generally known to be safe.

C Unclear or conflicting scientific evidence

• Acupuncture : Several attempts have been made to document benefits of stimulation of the P6 wrist point to reduce post-operative nausea and vomiting in children. Both acupuncture and acupressure wrist bands have been tried. Study results conflict. More trials are needed to make any firm conclusion regarding the use of acupuncture in adults and children.
• While several studies have suggested the related techniques of acupressure and other forms of nerve stimulation at the P6 wrist point may improve nausea during pregnancy, little study has been applied to use of acupuncture itself for this purpose. Thus the evidence in insufficient for reaching conclusions about acupuncture for nausea and vomiting of pregnancy.
• Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, neurological disorders, or if taking anticoagulants. Avoid on areas that have received radiation therapy and during pregnancy. Avoid electroacupuncture with irregular heartbeat or in patients with pacemakers. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with a history of seizures.
• Acustimulation : Transcutaneous acupoint electrical stimulation has been tested in limited available study of patients receiving electroshock therapy for mental illness, to determine whether it might reduce nausea and vomiting. The design of the study makes interpretation of results difficult. Therefore, more studies are needed to determine the potential benefits of acustimulation for electroconvulsive therapy-related nausea and vomiting.
• The evidence on the use of acustimulation wristbands for chemotherapy-induced nausea and vomiting is mixed. Some studies suggest no benefit and that simple acupressure massage may be more effective. Other studies have found benefit that when acustimulation is combined with anti-nausea medications; acustimulation bands may reduce the amount of medication needed and they may help with more severely nauseous patients. More studies are needed to clarify the relationships between patient responses, types of cancer, and types of chemotherapy.
• There is a lack of solid evidence on the effects of acustimulation for nausea and vomiting of pregnancy. Although experts express a general opinion that it is likely beneficial, well-designed studies are needed to document the benefits.
• Avoid if the cause of medical symptoms is unknown. Acustimulation devices may cause slight skin irritation under the electrodes when the wristband is used. Switch wrists to avoid. Acustimulation devices should only be used on the designated area. Use cautiously with pacemakers. Keep acustimulation devices out of the reach of children.
• Aromatherapy : Aromatherapy is a technique in which essential oils from plants are used with the intention of preventing or treating illness, reducing stress, or enhancing well-being. Preliminary evidence suggests that there may be no effect of aromatherapy on postoperative nausea and vomiting other than might be attributable to simple breathing or placebo effects. More studies are needed to determine whether or not aromatherapy may contribute to well-being in post-operative patients.
• Essential oils should be administered in a carrier oil to avoid toxicity. Avoid with a history of allergic dermatitis. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if driving/operating heavy machinery. Use cautiously if pregnant.
• Ginger : Some studies report that ginger has no effect on motion sickness, while other research notes that ginger may reduce vomiting (but not nausea). More studies are needed comparing ginger to other drugs used for this purpose.
• Initial human research reports that ginger may reduce the severity and duration of chemotherapy-induced nausea and vomiting. Other studies show no significant effects. Additional studies are needed to confirm these results and to determine safety and dosing. Numerous prescription drugs, such as 5HT3 inhibitors, are highly effective at controlling nausea in cancer patients undergoing chemotherapy, and the available options should be discussed with the patient's medical oncologist.
• Some human studies report improvement in postoperative nausea or vomiting if patients take ginger before surgery. However, other research shows no difference. Additional studies are needed.
• Avoid if allergic to ginger or other members of the Zingiberaceae family (like red ginger, Alpinia purpurata, shell ginger, Alpinia zeru, green cardamom, and balsam of Peru). Avoid with anticoagulation therapy. Avoid large quantities of fresh cut ginger with inflammatory bowel disease or with a history of intestinal obstruction. Use cautiously before surgery or with gastric or duodenal ulcers, gallstones, heart disease, or diabetes. Use cautiously long-term. Use cautiously in underweight patients. Use cautiously if taking heart medications or sedatives and if driving or operating heavy machinery. Use cautiously if pregnant or breastfeeding.
• Hypnosis : Several studies report on the use of hypnotherapy in people with nausea and vomiting related to cancer chemotherapy, pregnancy (hyperemesis gravidarum), and surgical recovery. Results are mixed and there is no reliable comparison to anti-nausea medications or other relaxation techniques. Better research is needed before a firm conclusion can be drawn.
• Use cautiously with mental illnesses, such as psychosis/schizophrenia, manic depression, multiple personality disorder, or dissociative disorders. Use cautiously with seizure disorders.
• Peppermint : Peppermint (Mentha x piperita), a perennial herb growing to the size of one meter and found throughout much of Europe and North America, has a long history of use for digestive disorders. More research is needed to determine if peppermint inhalation is an effective treatment for post-operative nausea.
• Avoid if allergic to peppermint oil or members of the Lamiaceae family. Avoid topical use of peppermint oil around the facial or chest areas of infants and young children, especially around the nose. Avoid injection of peppermint oil. Use cautiously in patients with gastroesophageal reflux disease, achlorhydria, G6PD deficiency, gallbladder disease, hiatal hernias, or kidney stones.
• TENS : Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. TENS is usually performed in conjunction with acupuncture treatments. Electrodes are temporarily attached with paste in various patterns, depending on the specific condition and treatment goals. Although limited available study found positive results when using TENS with post-operative nausea and vomiting, more research is needed. There is also not enough reliable evidence to draw a firm conclusion on the use of TENS for nausea and vomiting of pregnancy.
• Avoid with implantable devices, such as defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously with decreased sensation (such as neuropathy) or with seizure disorders. Avoid if pregnant or breastfeeding.

D Fair negative scientific evidence

• Acustimulation : Limited study suggests that using ReliefBand® to stimulate the P6 wrist point may not reduce gastroscopy-related nausea. Theoretically, future studies may contradict this finding, yet the nausea and retching is caused by the invasiveness of the procedure itself, rather than by internal factors in the patient, making it unlikely.
• Avoid if the cause of medical symptoms is unknown. Acustimulation devices may cause slight skin irritation under the electrodes when the wristband is used. Switch wrists to avoid. Acustimulation devices should only be used on the designated area. Use cautiously with pacemakers. Keep acustimulation devices out of the reach of children.