Cannabis Hyperemesis Syndrome: Repeated Vomiting Linked to Long-Term Cannabis Use

Cannabis hyperemesis syndrome (CHS) is a pattern of repeated, severe bouts of nausea and vomiting in people who have used cannabis often and for a long time. “Hyperemesis” simply means heavy vomiting. Medical papers use two names for the same condition — cannabis hyperemesis syndrome and cannabinoid hyperemesis syndrome. It was first described in a 2004 case series from South Australia, and the Rome IV classification of gut disorders, published in 2016, lists it as one of three nausea and vomiting disorders.

The condition is a paradox: cannabis is widely used to calm nausea, yet in this syndrome long-term use is linked to vomiting that ordinary anti-sickness medicines often fail to stop. This page sets out how the condition is defined, what the typical pattern looks like, how often emergency departments see it and how that changed after legalization, the ideas researchers have put forward to explain it, how it differs from cyclic vomiting syndrome, the hospital treatments that have been tested and what they found, the complications in published reports, what follow-up studies found about stopping cannabis, and what is still unknown.

Table of Contents

  1. The Definition and the Rome IV Criteria
  2. The Typical Pattern
  3. How Common It Is Among Heavy Users
  4. Emergency Visits Before and After Legalization
  5. Proposed Mechanisms, Stated as Hypotheses
  6. How It Differs From Cyclic Vomiting Syndrome
  7. Hospital Treatments Reported in Studies
  8. Complications Reported
  9. What Follow-Up Studies Found About Stopping Cannabis
  10. What Is Not Known
  11. Key Research Papers
  12. Connections
  13. Featured Videos

The Definition and the Rome IV Criteria

The Rome criteria are the international definitions used for gut disorders that are diagnosed from their pattern of symptoms rather than from a single test. The 2016 Rome IV paper on stomach and upper-gut disorders sorted them into four groups. One group is the nausea and vomiting disorders, and it has three members: chronic nausea and vomiting syndrome, cyclic vomiting syndrome, and cannabinoid hyperemesis syndrome.

In outline, the Rome IV definition has three parts: vomiting episodes that resemble cyclic vomiting syndrome in how they start, how long they last and how often they return; a start after prolonged, heavy cannabis use; and episodes that go away when cannabis use stops for a sustained period. A 2022 systematic review summarizes the Rome IV requirement as cannabinoid use together with nausea and vomiting symptoms persisting over at least the past 6 months. Long, hot showers or baths during an episode count only as a supporting feature, not a requirement, according to a 2025 scoping review.

A 2017 systematic review that pooled 183 published articles described the condition in one sentence: a cyclic vomiting syndrome, preceded by daily to weekly cannabis use, usually accompanied by symptom improvement with hot bathing, and resolution when cannabis is stopped.

The Definition Is Still Debated

A 2019 review called cannabinoid hyperemesis syndrome a “putative” disorder and reported considerable controversy about how it is defined. Its authors wrote that most of the published data are varied in quality, with limited follow-up, so it is hard to tell whether chronic cannabis use causes the vomiting, is merely associated with cyclic vomiting syndrome, or unmasks or triggers symptoms in people already predisposed to cyclic vomiting syndrome. The authors went back through the published case series and case reports to count how many cases actually met the Rome IV criteria, described limits in the existing framework, and proposed revised diagnostic criteria.

The difficulty lies in the third part of the definition. Proving that episodes go away when cannabis stops takes a long period of watching after the person stops, and most published reports did not follow people for long. A 2025 scoping review states that a reliable distinction between this syndrome and cyclic vomiting syndrome is only possible once remission has been seen during at least 6 months without cannabis.

The Typical Pattern

The 2017 systematic review counted how often each feature appeared across the published cases. The most frequent were:

Those percentages come from case reports, which tend to describe the clearest cases, so they show what a typical published case looks like rather than how common each feature is in everyone with the condition.

Years of Frequent Use

The largest single-hospital case series, from the Mayo Clinic in 2012, identified 98 patients out of 1,571 records searched. All 98 were younger than 50. Where the length of cannabis use was recorded, 25 of 37 people (68%) had used cannabis for more than 2 years before the vomiting began, and where the frequency was recorded, 71 of 75 (95%) used it more than once a week. A 2022 systematic review reported that the length of cannabis use before symptoms ranged from 6 months to 11 years. The adults in the one randomized haloperidol trial, described further down, were on average 29 years old and used 1.5 grams of cannabis a day, having started at an average age of 19.

Cycles of Vomiting and Abdominal Pain

Episodes of intense nausea and vomiting come and go. In the Mayo Clinic series, 84 of the 98 patients (86%) reported abdominal pain. An Australian audit of 142 emergency department presentations between 2015 and 2021 found that cyclical nausea and vomiting was the most common feature, that patients were young (median age 31 years), that 68.7% were male, and that all had a history of regular, usually daily, cannabis use. Blood tests in that audit often showed a raised white-cell count (75.8%) and a mildly low potassium level (57.9%), while lipase, a marker of pancreas inflammation, was not raised and scans were mostly normal.

Relief From Hot Showers and Baths

The feature that first drew attention to the syndrome is the hot shower. In the original 2004 South Australian series, 9 of the 10 patients described showed an unusual washing behavior during episodes. In the Mayo Clinic series, the effect of hot water was recorded for 57 patients, and 52 of them (91%) reported relief of symptoms with hot showers or baths. People describe returning to the shower again and again during an episode. The relief lasts only while the heat lasts, and it does not end the episode.

The hot-shower habit is not unique to this syndrome. An internet survey of adults with cyclic vomiting syndrome, described below, found it was common in that condition too.

A Pattern That May Worsen Over Time

A 2025 scoping review describes a process it calls chronification: after several clusters of episodes, the threshold for the next cluster falls, and a return to cannabis, even at low doses, is reported to bring stronger and longer clusters than before. This is the review authors’ summary of clinical reports rather than the result of a controlled study.

How Common It Is Among Heavy Users

The syndrome was long described as rare, but a 2018 study in the emergency department of the oldest public hospital in the United States set out to measure it. Researchers approached 2,127 patients aged 18 to 49; 155 of them smoked cannabis on at least 20 days a month. Of those 155, 32.9% (95% confidence interval 25.5% to 40.3%) met the study’s definition of having experienced the syndrome: nausea and vomiting, plus rating hot showers at 5 or more on a 10-point scale for relief. The authors estimated that, if the figure applied to the general population, about 2.75 million Americans (2.13 to 3.38 million) might experience a similar condition each year.

That study used a questionnaire and a broad definition, so it measures symptoms consistent with the syndrome rather than confirmed diagnoses. It does show that the pattern is far from unusual among people who smoke cannabis most days of the month, and also that most of the frequent users surveyed did not report it.

Emergency Visits Before and After Legalization

Three sets of figures track emergency department visits in places that changed their cannabis laws.

Colorado, After Medical Cannabis Was Liberalized in 2009

A study at one Colorado hospital looked at emergency visits for cyclic vomiting before and after the state’s 2009 liberalization of medical cannabis. Cyclic vomiting visits rose from 41 per 113,262 emergency visits to 87 per 125,095 emergency visits, a prevalence ratio of 1.92 (95% confidence interval 1.33 to 2.79). Patients in the later period were more likely to have cannabis use documented (odds ratio 3.59). The authors could not tell whether this reflected more cannabis use, more accurate reporting of use, or both. The study counted all cyclic vomiting visits, not only those labelled as cannabis hyperemesis syndrome.

Ontario, Canada, From 2014 to 2021

Canada legalized recreational cannabis in October 2018. A study of everyone aged 15 and over covered by Ontario’s public health insurance counted 12,866 emergency visits for cannabis hyperemesis syndrome from 8,140 people between January 2014 and June 2021. The mean age was 27.4 years, 34.8% of the individuals were aged 19 to 24, and 51.5% were female. Nearly 10% of visits (1,135 visits, 8.8%) led to a hospital admission. Monthly visit rates rose 13-fold, from 0.26 visits per 100,000 people in January 2014 to 3.43 per 100,000 in June 2021.

The timing matters. Legalization itself, with limits on products and stores, was not associated with an immediate or gradual change in visit rates. The jump came with commercialization — more stores and new products — which overlapped with the COVID-19 pandemic: that period was associated with an immediate rise in visit rates (incidence rate ratio 1.49; 95% confidence interval 1.31 to 1.70). The increase was larger in women and in people old enough to buy cannabis legally than in men and in people under the legal age.

The United States, After a New Diagnosis Code in 2025

On October 1, 2025, United States doctors gained a diagnosis code specific to cannabis hyperemesis syndrome. A Centers for Disease Control and Prevention report counted 199,565 emergency visits involving the syndrome between January 2023 and May 2026. The share of visits stayed mostly steady until September 2025, then rose from 3.35 per 10,000 emergency visits in September 2025 to 11.26 per 10,000 in October 2025. Over the first 8 months with the new code, the average monthly share was 3.7 times as high as the average from January 2023 to September 2025. Shares were higher among people aged 15 to 24 and among females. The report states that the abrupt, sustained increase might partly reflect better recognition and coding rather than a true rise in illness.

Proposed Mechanisms, Stated as Hypotheses

No one has shown what causes the syndrome. The 2017 systematic review concluded that the underlying biology remains unclear, with little research dedicated to it. The ideas below are hypotheses that researchers have proposed to fit the observations.

Changes in the Cannabinoid Receptors

Tetrahydrocannabinol (THC), the main intoxicating compound in cannabis, acts largely through the cannabinoid type 1 receptor, which is found in the brain and in the nerves of the gut. One hypothesis holds that heavy, long-term exposure changes how these receptors respond, so that a drug that eases nausea in occasional use is linked to vomiting in heavy use. A 2018 review describes the syndrome as possibly resulting from a disturbance of the body’s own cannabinoid signalling system after long-term stimulation from outside, in a setting of cannabinoid receptor desensitization.

There is direct evidence that the receptors do change in heavy users, though not specifically in people with this syndrome. A 2012 brain-imaging study using positron emission tomography found fewer cannabinoid type 1 receptors in parts of the brain’s outer layer (cortex) in people who smoked cannabis daily. The reduction was larger in those who had smoked for more years, and after about 4 weeks of monitored abstinence on a secure research unit, receptor levels returned to normal. Whether this receptor change is what drives the vomiting has not been tested.

The Heat Receptor and Hot Water

The second hypothesis tries to explain why hot water helps. Transient receptor potential vanilloid 1 (TRPV1) is a receptor on nerve endings that responds to heat above 43 °C, to acid, and to capsaicin, the compound that makes chili peppers burn (see the animation Why Chili Burns). A 2018 review proposes that hot showers relieve symptoms by switching on this receptor through heat, and that capsaicin cream rubbed on the abdomen may copy the same effect. The review lists several downstream signals that could follow — changes in nerve messengers such as tachykinins, somatostatin and calcitonin gene-related peptide, and in histamine, acetylcholine and serotonin signalling — as possible explanations, not proven ones. A 2022 review of the same receptor states that the mechanism of the syndrome is unknown, and suggests that hot water and capsaicin may act through the vagus nerve and the brainstem areas that control nausea and vomiting.

The same receptor is also part of how cannabinoids act in the body, which is why researchers see a possible link between long-term cannabis use and a heat-sensing pathway. That link remains a theory.

Possible Genetic Differences

Only some heavy users develop the syndrome, which raises the question of individual susceptibility. A 2022 study recruited through an online questionnaire: of 585 respondents, 205 qualified as patients and 54 as cannabis-using controls without symptoms, and 28 patients and 12 controls completed genetic testing. The patients more often carried variants in genes affecting brain messengers (catechol-O-methyltransferase and the dopamine D2 receptor), the heat receptor described above, a liver enzyme involved in breaking down cannabinoids (cytochrome P450 2C9), and a cholesterol transporter (ATP-binding cassette transporter A1). The authors called the findings preliminary, noting that the sample was smaller than they wanted and that only 28 of 99 patients who agreed to testing returned a kit.

How It Differs From Cyclic Vomiting Syndrome

Cyclic vomiting syndrome produces the same kind of stereotyped vomiting episodes separated by well periods, and it occurs in people who do not use cannabis. The two conditions overlap so much that telling them apart is one of the main problems in this field.

Cannabis Use and Hot Showers Are Common in Cyclic Vomiting Syndrome Too

A 2014 internet survey of adults diagnosed with cyclic vomiting syndrome had 514 participants, 437 of whom answered the questions on cannabis. Of these, 81% had used cannabis and 19% never had; 54% used it for health reasons and 43% recreationally. Users said it improved nausea, appetite, general well-being, stress and vomiting. Sixty-seven percent of patients reported taking hot showers or baths for relief. Hot bathing was associated with cannabis use (odds ratio 2.54), but the authors concluded that hot showers were not a sign unique to cannabis use. A 2025 scoping review states that about 30% of people with cyclic vomiting syndrome also use cannabis chronically.

What Separates Them

A 2017 German review concluded that complete and lasting resolution of all symptoms after stopping cannabis is the only reliable way to tell the two apart. It reported that compulsive bathing, once attributed only to cannabis hyperemesis syndrome, is equally present in cyclic vomiting syndrome. It named psychiatric conditions such as panic attacks and depression, a history of migraine, and rapid stomach emptying as features that support a diagnosis of cyclic vomiting syndrome, and it noted that long-term follow-up of either condition is rarely published.

A 2025 study from 5 medical centers in Mexico compared 30 patients with cyclic vomiting syndrome and 16 with cannabis hyperemesis syndrome, all diagnosed by the Rome IV criteria. The cannabis group was somewhat older (median age 27 versus 23 years), smoked tobacco more often (50.0% versus 26.7%) and more often reported risky alcohol use (31.3% versus 0.0%). Cannabis use was reported by 13.3% of the cyclic vomiting group. The time to diagnosis was longer for cyclic vomiting syndrome (35.4 months) than for cannabis hyperemesis syndrome (26.5 months), and the two groups did not differ in hospital admissions or length of stay.

Because the distinction depends on what happens after cannabis is stopped, emergency departments mostly see people for whom the diagnosis is still uncertain. The 2025 scoping review describes these as mixed or “suspected” cases.

Hospital Treatments Reported in Studies

Studies describe the vomiting as often resistant to standard anti-sickness medicines. The 2017 systematic review listed supportive care with intravenous fluids, dopamine-blocking medicines, topical capsaicin cream, and not using narcotic (opioid) painkillers as approaches that showed some benefit during an acute episode. The research base is small: a 2024 systematic review for the Society for Academic Emergency Medicine found only seven studies of direct evidence for capsaicin or dopamine-blocking drugs in adults in the emergency department — five observational studies and two randomized controlled trials, with 492 patients in total. Decisions about any medicine belong with a clinician; what follows reports what the studies found.

Haloperidol Compared With Ondansetron: the HaVOC Trial

Haloperidol is an older antipsychotic medicine that blocks dopamine receptors, including in the brain’s vomiting centre. Ondansetron is a standard anti-sickness medicine that blocks serotonin receptors. In the HaVOC trial, a triple-blind randomized trial published in 2021, cannabis users with active vomiting were randomized to intravenous haloperidol or intravenous ondansetron. The trial gave haloperidol at 0.05 or 0.1 mg per kilogram of body weight, or ondansetron 8 mg. The main outcome was the drop in abdominal pain and nausea, each measured on a 10-cm visual scale, 2 hours after treatment.

The trial was small, and it compared haloperidol with ondansetron rather than with placebo. The United States label for haloperidol injection does not list nausea or vomiting among its approved uses, and it states that the injection is not approved for intravenous use. The label adds that cases of sudden death, QT-interval prolongation (a change in the heart’s electrical rhythm) and the dangerous rhythm torsades de pointes have been reported with haloperidol, that intravenous use and higher-than-recommended doses appear to carry a higher risk of these rhythm problems, and that low potassium and low magnesium are among the conditions that add to that risk. The label also carries a boxed warning about increased deaths in elderly people with dementia-related psychosis treated with antipsychotic drugs.

The United States label for ondansetron injection lists prevention of nausea and vomiting with chemotherapy and after surgery as its approved uses. It states that ondansetron prolongs the QT interval in a dose-dependent way, that torsades de pointes has been reported after marketing, and that heart-rhythm monitoring with an electrocardiogram is recommended in patients with electrolyte abnormalities such as low potassium or low magnesium.

Topical Capsaicin Cream

Capsaicin cream, rubbed on the skin of the abdomen, was tried because it acts on the same heat receptor as hot water. The results are mixed.

None of these studies compared capsaicin directly with haloperidol.

Benzodiazepines and Other Medicines

Benzodiazepines are calming medicines such as lorazepam. A 2017 systematic review of drug treatment for the syndrome found 63 eligible articles covering 205 people: 4 prospective studies, 3 retrospective studies, 12 case series and 44 case reports. In the case series and case reports, benzodiazepines, followed by haloperidol and capsaicin, were the treatments most often reported as effective for an acute episode; in prospective studies, lorazepam was discussed as an effective short-term treatment. Many other drugs appeared in single reports. The review concluded that high-quality evidence for any drug treatment is limited. A 2022 systematic review also listed droperidol, propranolol and aprepitant among treatments that showed symptom relief in reports.

Intravenous Fluids and Supportive Care

Fluids through a drip replace what is lost through vomiting and correct salt and mineral imbalances. In the Australian 6-year audit, treatment was supportive — anti-sickness medicines, intravenous fluids and pain relief — and there were no deaths or admissions to intensive care among those presentations.

Complications Reported

Most people recover from each episode, but repeated heavy vomiting has known consequences, and published reports describe the following.

Dehydration and Kidney Injury

A 2014 case report described a 25-year-old man with 8 years of daily cannabis use who arrived after more than a day of “constant” vomiting. His blood creatinine, a marker of kidney function, was 3.21, and he was admitted with acute kidney failure attributed to the syndrome. In the literature, the authors found 5 other case reports of acute kidney failure among 55 case reports of the syndrome. They suggested that the combination of non-stop vomiting and constant hot showers puts people at risk of severe dehydration and of kidney failure caused by low blood flow to the kidneys. See Acute Kidney Injury for the wider condition.

Low Potassium and Other Salt Problems

Vomiting removes stomach acid, chloride and potassium. In the Australian audit, 57.9% of presentations showed mildly low potassium. Low potassium matters for the heart, and both drug labels described above name it in their heart-rhythm warnings. The site’s pages on low potassium and on low chloride from vomiting and dehydration describe these changes in detail.

Deaths in Case Reports

Deaths are reported only in individual case reports, so they show that death is possible, not how often it happens.

Hospital Admission and Treatment Side Effects

In Ontario, 8.8% of emergency visits for the syndrome led to a hospital admission. Treatments carry their own reported harms: acute dystonia after the higher haloperidol dose in the HaVOC trial, and skin irritation from capsaicin cream in the pilot trial.

What Follow-Up Studies Found About Stopping Cannabis

Stopping cannabis is the only measure that follow-up studies have consistently linked to episodes ending. The hospital treatments described above were studied for relief during a single episode, not for preventing future ones. The follow-up evidence itself is thin, and every figure below comes from small or self-selected groups.

The same weaknesses run through these numbers. The 2019 review noted that most reports have limited follow-up, and the 2017 German review noted that long-term follow-up is rarely published. A 2025 scoping review states that full remission, which it defines as at least 5 years without symptoms, comes only with sustained abstinence. The 2017 drug-treatment review found tricyclic antidepressants discussed as an effective long-term treatment in one prospective study, and none of the reviews read for this page describes a controlled trial of a medicine for preventing episodes in people who keep using cannabis.

How long it takes for episodes to stop after the last use has not been measured in a controlled way. The brain-imaging study described above found that cannabinoid receptor levels in daily smokers returned to normal after about 4 weeks of abstinence, but that study did not involve people with this syndrome, and whether it explains the timing of recovery is unknown. Cannabis use disorder, the medical term for difficulty cutting down despite harm, is a separate condition; the 2022 online survey found that 15.6% of its patients carried a diagnosis of cannabis dependency or addiction and 56.6% reported withdrawal symptoms.

What Is Not Known

Key Research Papers

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  4. Sorensen CJ, DeSanto K, Borgelt L, Phillips KT, Monte AA. Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophysiology, and Treatment-a Systematic Review. J Med Toxicol. 2017;13(1):71-87. PubMed PMID: 28000146
  5. Senderovich H, Patel P, Jimenez Lopez B, Waicus S. A Systematic Review on Cannabis Hyperemesis Syndrome and Its Management Options. Med Princ Pract. 2022;31(1):29-38. PubMed PMID: 34724666
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  12. Vivolo-Kantor AM, Liu S, Tanz LJ, Mattson CL, Schier J. Trends in Emergency Department Visits Involving Cannabis Hyperemesis Syndrome Identified Using a New Diagnosis Code - United States, January 2023-May 2026. MMWR Morb Mortal Wkly Rep. 2026;75(30):391-396. PubMed PMID: 42560855
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  15. Louis-Gray K, Tupal S, Premkumar LS. TRPV1: A Common Denominator Mediating Antinociceptive and Antiemetic Effects of Cannabinoids. Int J Mol Sci. 2022;23(17):10016. PubMed PMID: 36077412
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  17. Venkatesan T, Sengupta J, Lodhi A, Schroeder A, Adams K, Hogan WJ, Wang Y, Andrews C, Storr M. An Internet survey of marijuana and hot shower use in adults with cyclic vomiting syndrome (CVS). Exp Brain Res. 2014;232(8):2563-70. PubMed PMID: 24792504
  18. Blumentrath CG, Dohrmann B, Ewald N. Cannabinoid hyperemesis and the cyclic vomiting syndrome in adults: recognition, diagnosis, acute and long-term treatment. Ger Med Sci. 2017;15:Doc06. PubMed PMID: 28400711
  19. Felix-Tellez FA, Morel-Cerda EC, Jiménez-Castillo RA, Valdovinos-García LR, Gómez-Escudero O, Valdovinos-Díaz MÁ, Coss-Adame E, Velasco JAV, Monjaraz EMT, Montijo-Barrios E, Solís-Ortega AA, Frazier RJ, Venkatesan T, Remes-Troche JM. Clinical Characteristics and Associated Factors in Mexican Patients With Cyclic Vomiting Syndrome and Cannabinoid Hyperemesis Syndrome. J Neurogastroenterol Motil. 2025;31(3):330-339. PubMed PMID: 40625249
  20. Ruberto AJ, Sivilotti MLA, Forrester S, Hall AK, Crawford FM, Day AG. Intravenous Haloperidol Versus Ondansetron for Cannabis Hyperemesis Syndrome (HaVOC): A Randomized, Controlled Trial. Ann Emerg Med. 2021;77(6):613-619. PubMed PMID: 33160719
  21. Dean DJ, Sabagha N, Rose K, Weiss A, France J, Asmar T, Rammal JA, Beyer M, Bussa R, Ross J, Chaudhry K, Smoot T, Wilson K, Miller J. A Pilot Trial of Topical Capsaicin Cream for Treatment of Cannabinoid Hyperemesis Syndrome. Acad Emerg Med. 2020;27(11):1166-1172. PubMed PMID: 32569429
  22. Kum V, Bell A, Fang W, VanWert E. Efficacy of topical capsaicin for cannabinoid hyperemesis syndrome in a pediatric and adult emergency department. Am J Emerg Med. 2021;49:343-351. PubMed PMID: 34242945
  23. Pourmand A, Esmailian G, Mazer-Amirshahi M, Lee-Park O, Tran QK. Topical capsaicin for the treatment of cannabinoid hyperemesis syndrome, a systematic review and meta-analysis. Am J Emerg Med. 2021;43:35-40. PubMed PMID: 33493995
  24. Sabbineni M, Scott W, Punia K, Manuja K, Singh A, Campbell K, MacKillop J, Balodis I. SAEM GRACE: Dopamine antagonists and topical capsaicin for cannabis hyperemesis syndrome in the emergency department: A systematic review of direct evidence. Acad Emerg Med. 2024;31(5):493-503. PubMed PMID: 37391387
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Drug-label facts on this page come from the United States prescribing information for haloperidol injection and ondansetron injection, as published on DailyMed by the National Library of Medicine.

PubMed Topic Searches

  1. PubMed: cannabinoid hyperemesis syndrome
  2. PubMed: cannabis hyperemesis emergency visits and legalization
  3. PubMed: haloperidol and capsaicin for cannabis hyperemesis
  4. PubMed: cannabis hyperemesis versus cyclic vomiting syndrome

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