Vestibular causes of nausea and vomiting in palliative care

Nausea and vomiting from vestibular causes may be due to benign paroxysmal positional vertigo, labyrinthitis or Ménière disease. However, in patients with palliative care needs, a new presentation of this type of nausea and vomiting can suggest metastases to the bony base of the skull or cerebellar metastases. The nausea is characterised by complaints of dizziness or vertigo, or worsening nausea with movement, especially of the head or a change in posture.

For management of nausea and vomiting from vestibular causes in patients with palliative care needs, use:

1prochlorperazine 5 to 10 mg orally, 6- to 8-hourly prochlorperazine

OR

2promethazine 25 to 50 mg orally, 8- to 12-hourly. Maximum dose 100 mg daily promethazine

OR

3haloperidol 0.5 to 1 mg orally, twice daily, and 0.5 to 1 mg 4-hourly as required. Maximum dose 5 mg daily haloperidol

OR

3haloperidol 0.5 to 1 mg subcutaneously, twice daily, and 0.5 to 1 mg 4-hourly as required. Maximum dose 5 mg daily. haloperidol

For patients with a continuous subcutaneous infusion (CSCI), use:

haloperidol 1 to 2.5 mg/24 hours by continuous subcutaneous infusion. haloperidol

Review antiemetic therapy to assess treatment response and check if the cause of the nausea has subsided. If initial therapy was not effective, switch to another drug. If nausea or vomiting continues despite optimal therapy, seek specialist palliative care advice.

For management of dizziness or vertigo, see ‘Dizziness’ in palliative care.