Researchers at Childrens Hospital Los Angeles, CA conducted a retrospective chart review of 42 patients treated with co-enzyme Q10 and L-carnitine, and the addition of amitryptiline (or cyproheptadine for <5 year olds) in refractory cases. Patients ate 3 meals and 3 snacks a day and avoided fasting. Treatment was monitored with blood levels: co-enzyme Q10 >3.0 mg/L; L-carnitine >40 micromolar; amitryptiline >150 ng/ml; cyproheptadine dose 0.5 mg/kg/day. In 30 cases with available outcome data, vomiting episodes resolved in 23, and improved by >50-75% in 4 cases. Treatment withmitochondrial-targeted cofactors (co-enzyme Q10 and L-carnitine) plus amitryptiline was highly effective in the prevention of vomiting episodes. 
COMMENT. The author observes that these findings need confirmation by a prospective blinded trial in unselected cases. Cyclic vomiting is usually regarded as a form of migraine, and mitochondrial dysfunction may be a factor in etiology of both cyclic vomiting and migraine. Cyclic vomiting, sometimes associated with epilepsy and epileptiform EEG, may also respond to treatment with antiepileptic agents (topiramate, valproate).