MILITARY MEDICINE, 182, 11/12:e1846, 2017

Management of Sea Sickness in Susceptible Flight Crews

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LTC Nicole Powell-Dunford, MC USA*†; Lt Col Alaistair Bushby, RAMC‡

ABSTRACT Introduction: Sea sickness may greatly impact the readiness of Service personnel deployed aboard
naval vessels. Medications used in the treatment of sea sickness may have adverse effects, limiting their use as flight
crew. Although the prevalence of sea sickness in flight crews remains unclear, individual susceptibility and high sea
states are established risk factors. Literature review can guide optimized management strategies for this population.
Materials and Methods: The first author conducted a PubMed search using the terms “sea sickness” “flight crew”
“scopolamine,” “hyoscine,” and “cinnarizine,” identifying 15 articles of 350 matches, which addressed potential
impact to flight performance. Analysis also included two historic reports about motion sickness maintained within the
U.K. Army Aviation Centre’s aeromedical archives in Middle Wallop, Hampshire. Both authors reviewed aeromedical
policy for the International Civil Aviation Organization, U.K. Civil Aviation Authority, U.S. Federal Aviation Author-
ity, the National Aeronautics Space Administration, U.S. Army, U.S. Navy, and U.S. Air Force. Results: Scopol-
amine, also known as hyoscine, has fewer operationally relevant side effects than cinnarizine or first-generation
antihistamines. Although no aeromedical authorities endorse the unsupervised use of scopolamine, many will consider
authorizing its temporary use following an initial assessment on the ground. Evidence supports the concomitant use of
stimulant medication for augmenting antinausea effects and countering the potential sedative effects of scopolamine.
Conclusions: Scopolamine should be considered as a first-line medication for flight crews at risk of sea sickness but
such use must be guided by the appropriate aeromedical authority, ideally in conjunction with a ground trial to evalu-
ate individual response. The limited evidence to support concurrent use of stimulants must be weighed against the
challenges of maintaining accountability of controlled substances in the operational environment.

INTRODUCTION sickness or medication side effects could prove especially

Authors have described motion sickness during naval opera-
tions since the time of ancient Greece.1 Even mild degrees
of sea sickness can significantly impact multiple aspects of
performance.2 Historically, military populations have used
scopolamine (hyoscine), cinnarizine, and first-generation
antihistamines to treat sea sickness3–8 with the most recent
operational research specifically evaluating scopolamine and
cinnarizine4,9–16 rather than the first-generation antihistamine
medication class, now well established as causing problem-
atic sedation.3,17–20 Since the birth of naval aviation on
November 14, 1910, when Ely’s Curtiss Pusher aircraft
launched from light cruiser USS Birmingham,21 many air
crews have been exposed to naval flight deck operations
along a continuum of risk for sea sickness—from days of
extended duty during a high sea state to an isolated rapid
refueling aboard a massive and stable aircraft carrier plat-
form. Health care providers contemplating the use of sea
sickness medications in flight crews must not only consider
the operational setting but also consider the impact of sea
sickness and sea sickness medications on human perfor-
mance. The detrimental cognitive effects from either sea
*Medical Centre, Army Aviation Centre, Middle Wallop, Stockbridge,
SO20 8DY, United Kingdom.
†U.S. Army Aeromedical Research Laboratory, 6901 Andrews Avenue,
Fort Rucker, AL 36362-0577.
‡Headquarters, Army Aviation Centre, Middle Wallop, Stockbridge,
SO20 8DY, United Kingdom.
This manuscript does not reflect the views or opinions of the U.S.
Department of Defense or the U.S. Army.
doi: 10.7205/MILMED-D-17-00029
devastating in this occupational cohort.
Two predominant theories of motion sickness currently
exist. The hypothesis of sensory conflict postulates that
motion sickness is caused by a mismatch between the cur-
rent pattern of sensory inputs about self-movement and the
pattern that is expected on the basis of previous experience.
The hypothesis of postural instability theory postulates that
motion sickness is caused by loss of postural control. There
is presently more evidence for the sensory conflict theory,
with researchers also hypothesizing contributory roles for
visceral afference, thermoregulation, neuroendocrine, and
epigenetic modulation factors.22,23
First-generation antihistamines such as diphenhydramine
carry an unacceptable risk of somnolence and are prohibited
for use in flight crew.5–8,24,25 Cinnarizine is an atypical anti-
histamine with calcium channel blocking abilities used in
the treatment of motion sickness, vertigo, and Meniere’s dis-
ease; it is thought to work by interfering with the signal
transmission between the vestibular apparatus of the inner
ear and the vomiting center of the hypothalamus by limiting
the activity of the vestibular hair cells.26 Although not avail-
able for prescription in the United States, cinnarizine has
been used extensively by the British Royal Navy. Scopol-
amine is a competitive antagonist at muscarinic acetylcho-
line receptors and is used extensively for the prevention and
treatment of motion sickness. Scopolamine works by acting
on the maculae of the utricle and saccule. Some providers
may prescribe concomitant stimulant medications to counter
potential performance decrements associated with antinausea
medication use.

e1846 MILITARY MEDICINE, Vol. 182, November/December 2017

 Sea Sickness in Flight Crews
This focused literature review was undertaken in an effort
to identify optimal sea sickness medication(s) for flight
crews. To date, no studies have assessed the actual use of
sea sickness medication in aircrew with ship board duties.
However, this focused literature review may help elucidate
the optimal sea sickness medications in this occupational
cohort, filling a gap in current operational knowledge.
METHODS
Literature from several sources was reviewed between August
2016 and December 2016. The first author conducted a sys-
temic PubMed search using the terms sea sickness, flight crew,
scopolamine, hyoscine, and cinnarizine, identifying 15 articles
from 350 matches which addressed potential impact of these
medications on flight performance. The term sea sickness
rather than motion sickness was used to identify literature
most relevant to the research topic. First-generation antihis-
tamines and meclizine were not included as part of the medi-
cation search terms because of their established lack of
suitability in flight crews per current military aeromedical
policies. Because of the small number of studies obtained
through the search, none were excluded on the basis of pub-
lication date. Articles describing concurrent assessment of
other medications apart from scopolamine and cinnarizine
were not excluded from analysis. Review also included two
historic reports about motion sickness maintained within the
U.K. Army Aviation Centre’s aeromedical archives in Mid-
dle Wallop, Hampshire. Both authors reviewed aeromedical
policy for the British Army, U.K. Civil Aviation Authority
(CAA), U.S. Federal Aviation Authority (FAA), the National
Aeronautics Space Administration (NASA), U.S. Army, U.S.
Navy, and U.S. Air Force.
RESULTS
Consistent good-quality patient-oriented evidence supports
scopolamine as a first-line medication for preventing motion
sickness for individuals who wish to maintain wakefulness,
with inconsistent and/or limited quality patient-oriented
research, substantiating the use of a first-generation antihista-
mine as an alternative.27 Table I outlines the basic pharma-
cologic properties of the scopolamine patch, a mode of
TABLE I. Scopolamine Patch Information28
Dosage Administration Storage
1.5 mg formulated to Apply to the hairless 20–25°C
deliver approximately area behind one (68–77°F)
1 mg of scopolamine ear at least 4 hours
over 3 days before exposure
Wash hands with soap
and water after application
and removal to avoid
ocular contamination
Patch is common mode for scopolamine in the management of motion sickness.
MILITARY MEDICINE, Vol. 182, November/December 2017
delivery used in the management of sea sickness. In the
most comprehensive analysis of scopolamine trials, 14 stud-
ies enrolling 1,025 subjects were reviewed. Evidence com-
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paring the effectiveness of scopolamine to cinnarizine or
combinations of scopolamine and ephedrine is equivocal or
minimal. No evidence exists for the use of scopolamine
alone or in combination with any other medication for the
treatment of established motion sickness symptoms.16 The
absorption and excretion of scopolamine varies greatly
among individuals, with up to six-fold variation in patch
users and a three-fold variation in oral users.27
Diverse motion sickness delivery systems and operation-
ally relevant performance impacts are described within the
literature. A review of transdermal scopolamine commis-
sioned by the U.K. Institute of Aviation Medicine deter-
mined that the scopolamine patch’s slow drug release
enables effective blood levels to be maintained for 72 hours,
with minimization of side effects; however, the patch
requires 6 to 8 hours for effectiveness and can be associated
with visual blurring when worn over 24 hours, especially in
hypermetropes.9 Mydriasis resulting from ocular contamina-
tion through a finger has been reported.15 A study conducted
at the German Air Force Institute of Aviation Medicine
determined that scopolamine nasal spray was effective and
safe for the treatment of motion sickness with a fast onset of
action (within 30 minutes) and with no signs of nasal or epi-
pharyngeal irritation.10
Several operationally oriented studies have assessed per-
formance impact of seasickness medication. A British analy-
sis of six sea trials predating 1990 determined transdermal
scopolamine to be superior to 50 mg dimenhydrinate for the
control of sea sickness, with most significant antinausea
effects appreciated during early days at sea, before adapta-
tion to the motion of the ship has occurred.9 The Israel
Naval Institute has undertaken the largest of these studies,
initially publishing results from a randomized double-blind,
placebo-controlled cross-over study in 2001. In this trial,
researchers assessed the objective performance and self-
reported well-being of 60 young naval crew in the compari-
son of a single 100 mg dose of dimenhydrinate, a single
50 mg dose of cinnarizine, and a single transdermal
Adverse Reactions Withdrawal Symptoms Idiosyncratic Reactions (Rare)
Two-thirds may Abrupt removal Acute toxic psychosis,
experience dry mouth may cause dizziness, including confusion,
Less than 20% nausea, vomiting, agitation, speech
experience sedation abdominal cramps, disorder, hallucinations,
sweating, headache, paranoia, and delusions
mental confusion,
muscle weakness,
slow heart rate,
and low blood pressure
e1847
 Sea Sickness in Flight Crews
scopolamine patch. Although dimenhydrinate was associated
with performance decrements and decreased well-being,
neither the cinnarizine nor the transdermal scopolamine
impacted performance or reported well-being. Dry mouth
was the only adverse effect reported by the sailors, in associ-
ation with scopolamine use.3 In a sea trial published in
2012, the Israel Naval Medical Institute compared a 1.5 mg
transdermal scopolamine patch with 25 mg cinnarizine pills
through a double-blind, randomized, cross-over study of 76
navy crew on two deployments. Subjects reported the sco-
polamine patch to be significantly more effective than
the cinnarizine tablet and attributed a “moderate-to-high”
degree of drowsiness more frequently to cinnarizine (34%)
than to the scopolamine patch (17%). Subjects reported
side effects more frequently with cinnarizine (38%) than
with the scopolamine patch (22%); comparison with pla-
cebo was only of borderline significance. A significantly
greater percentage of subjects preferred transdermal scopol-
amine to cinnarizine.4
A U.K. Royal Navy survey assessed 12 adult males in a
double-blind cross-over study comparing 0.6 mg scopol-
amine to 30 mg cinnarizine, each administered three times a
day. Both medications significantly impacted memory and
four-choice reaction time without impact on mood. Repeated
doses of scopolamine led to increasingly distant near point
convergence values, which were not clinically significant.13
In a smaller study involving six men, British researchers
conducted a placebo-controlled, double-blind, cross-over
design assessment of the sedative effects of cinnarizine
using 10 mg promethazine as a control. 15 mg doses of
cinnarizine did not impact performance but were associated
with sleepiness at 5 hours. 30 mg and 4 mg doses signifi-
cantly impacted performance at 5 hours.12
Some medical providers use sea sickness medications in
combination with stimulants, given the improvements in
reaction times, vigilance, and learning noted in adult males
taking stimulant medication.29 In a 1968 study, Wood et al
noted that six different combinations of motion sickness
medications and stimulants achieved an increased tolerance
for head movements associated with motion compared to
scopolamine monotherapy, with scopolamine delivered in
doses from 0.3 to 1.2 mg.19 Other studies demonstrate that
codelivery of scopolamine 1 mg and 1.2 mg in combination
with 10 mg dexedrine is superior compared to delivery of
scopolamine 1 mg alone in terms of tolerance for motion.18
In 1985, Wood et al assessed various motion sickness
and stimulant medication combinations in a series of trials
involving 10 subjects. Delivery of 1 mg doses of scopol-
amine in conjunction with 10 mg amphetamine was associ-
ated with significant performance improvement compared to
baseline performance on a computerized tracking test with
good operational correlation. Lower doses of amphetamine,
delivered independently or in conjunction with a variety
of motion sickness medications, were not able to raise
computerized performance scores above baseline. Doses
e1848
of 0.8 mg and 1.0 mg scopolamine significantly reduced
subject performance on computerized tracking, as did
25 mg doses of promethazine delivered through either the
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IM or oral route.20
In a small trial published in 1988, researchers from
Massachusetts Institute of Technology determined that eight
subjects treated with 0.4 mg oral scopolamine and 5.0 mg
oral dextroamphetamine did not experience any decrements
in Symbol-Digit Substitution, Simple Reaction Time, Pattern
Recognition, Digit Span Memory, and Pattern Memory,
although noting that higher doses of either medication have
been reported to be associated with performance decrements
in earlier studies.14 Estrada et al evaluated various motion
sickness medications in healthy nonaviator male passengers
exposed to turbulent helicopter flight, specifically evaluating
the use of 25 mg of promethazine in combination with
200 mg caffeine, 25 mg meclizine, a 1.5 mg scopolamine
patch, an acustimulation wristband and placebo in four
groups of 16 subjects, respectively. Each subject participated
twice—once with a treatment and once with placebo. Only
the promethazine and caffeine combination group showed a
statistically significant reduction in nausea and motion sick-
ness severity, and an improvement in reaction time when
compared with its placebo control.17 NASA’s reduced grav-
ity program assessed oral Scop/Dex (0.4 mg scopolamine/
5 mg dexedrine) to be free from operationally visual side
effects; this medication causes dry mouth as well as
nonclinically significant changes in pupil size and near point
accommodation with no decrement in visual acuity.11 The
most recent study assessing combinations of motion sickness
and stimulants determined that the efficacy of scopolamine
with modafinil (1 + 10 mg/kg) was equivalent to that of
scopolamine with d-amphetamine (1 + 1 mg/kg).30
Military and civil aeromedical authorities provide
diverging guidance regarding the management of motion
sickness; neither provides specific guidance for the man-
agement of sea sickness as an environmentally specific
condition. Most aeromedical authorities take a case by case
approach with a temporary authorization of specific motion
sickness medication(s). U.S. commercial pilots currently
require FAA approval to use medication for motion sick-
ness.25 The U.S. Army permits pilots to use promethazine
(Phenergan) 25 mg combined with ephedrine 25 mg or
L-scopolamine hydrobromide alone or in combination with
dextroamphetamine (Scop/Dex) for up to three flights dur-
ing training or for reacclimation provided the pilot is
accompanied by an instructor pilot with no waiver require-
ment.7 The U.S. Navy does not consider motion sickness
to be disqualifying in student aviators when it is transient,
resolving spontaneously or when addressed according to
specific Chief of Naval Air Training Instruction. Ginger,
250 mg up to 1 g, may be taken by U.S. Navy flight crew
members before situations where motion sickness may be
an issue without waiver requirement; however, dosage can-
not exceed a total of 4 g daily.8 In the U.S. Air Force,
MILITARY MEDICINE, Vol. 182, November/December 2017
 Sea Sickness in Flight Crews
airsickness requiring pharmacologic therapy beyond the
service’s established Airsickness Management Program is
disqualifying and not eligible for waiver. Approved medi-
cations, when used as part of this program, include trans-
dermal scopolamine 0.5 mg/dextroamphetamine sulfate
5 mg (Scop/Dex patch), given 1 to 2 hours before flight for
three consecutive flights for one flight per day. Flight sur-
geons can consider scopolamine hydrobromide 0.45 mg in
15 mL of elixir with dextroamphetamine sulfate 7.5 mg, or
other approved medications as alternatives.5
The U.K. civil aviation authority considers aeromedical
examiner directed use of cinnarizine or cyclizine for the pre-
vention of motion sickness provided 2 days of initial use on
the ground and the absence of any sedation with use.24 The
U.K. Royal Air Force Manual—Assessment of Medical Fit-
ness (2016) states that hyoscine hydrobromide or cinnarizine
is normally only prescribed for limited periods to aircrew in
training. Because of potential side effects, pilots using such
medications are unfit for solo flying and must fly with a pilot
suitably qualified on type.6
DISCUSSION
Well-established variations in individual responses to sco-
polamine as well as a range of doses and delivery options
may account for differences in side effects, reported well-
being, and performance in various antimotion sickness trials.
The preponderance of evidence suggests that scopolamine is
the first-line medication for those who need to preserve opti-
mum performance in an operational environment, with
cinnarizine as an alternative, which is clearly superior to
first-generation antihistamines. Clinicians should realize that
some important side effects may occur in therapeutic doses
of scopolamine. Evaluating individual response to specific
dose and delivery mode is a prudent aeromedical policy. An
imperfect therapeutic approach has resulted in notable varia-
tions in civil and military aeromedical policy for the man-
agement of motion sickness. Some evidence supports the
use of stimulant medication, as delivered concurrently, to
scopolamine to counter what may be subtle performance
decrements. However, controlled substances require special
handling and storage considerations as they present a risk of
diversion and misuse. Benefits of concurrent administration
of caffeine rather than a scheduled drug include reduced risk
for abuse, reduced risk for psychotic reaction, and a reduc-
tion in the logistical constraints of obtaining and storing a
controlled substance. Benefits of caffeine stimulation must
be weighed against diuretic effects, especially in the hot
weather environment. The use of a combination of caffeine
and scopolamine has not been studied but could afford oper-
ational benefit.
There are several limitations to this review and its useful-
ness in its application to military flight crews. To date, stud-
ies have mostly assessed the performance impact of sea
sickness medications in healthy males in the absence of pro-
vocative stimuli, using computerized performance assess-
MILITARY MEDICINE, Vol. 182, November/December 2017
ments rather than observation of assigned operational duties.
Furthermore, the aeromedical policy review was limited to
U.K. and U.S. aeromedical authorities. Further exploration
Downloaded from https://academic.oup.com/milmed/article/182/11-12/e1846/4661611 by The University of North Carolina at Chapel Hill Libraries user on 26 February 2021
of other military aeromedical policy may provide further
insights regarding the administration of sea sickness medica-
tions to flight crews. Comprehensive international aero-
medical policy review was beyond the scope of this review.
Importantly, the magnitude and duration of exposure to a pro-
vocative environment may vary considerably across shipboard-
deployed air crew members, requiring a nuanced approach to
the prevention and management of sea sickness. For the long-
term deployment of aircrew aboard naval vessels, individuals
with known sensitivity to sea sickness should be proactively
managed. A brief refueling sortie on a large aircraft carrier
would probably have negligible impact on aircrew, whereas
patient movement associated with a delay in takeoff secondary
to recovery of medical equipment and/or nonpermissive
departure conditions may provoke sea sickness, especially in
a nonhabituated crew landing aboard a small vessel in a high
sea state. In these instances, contingency availability of med-
ications could prove useful but timing their administration is
problematic as the greatest benefit requires treatment before
symptoms have begun.
CONCLUSION
Although the use of motion sickness in aircrew with duties
aboard navy ships has not been formally assessed, pertinent
literature supports the use of scopolamine and/or scopolamine-
stimulant combination medications for those with a known
predisposition toward motion sickness while aboard ships.
The requirement for special handling and storage of con-
trolled substances makes scopolamine without concurrent
administration of a stimulant medication the easiest motion
sickness medication to use. Further research regarding the
incidence of sea sickness in embarked flight crews can help
better inform this problem.
REFERENCES
1. Hippocrates. Aphorisms 4, sec 14. Translated by Francis Adams. Avail-
able at http://www.greektexts.com/library/Hippocrates/Aphorisms/eng/
147.html; accessed April 4, 2017.
2. Matsangas P, McCauley ME, Becker W: The effect of mild motion
sickness and sopite syndrome on multitasking cognitive performance.
Hum Factors 2014; 56(6): 1124–35.
3. Gordon CR, Gonen A, Nachum Z, et al: The effects of dimenhydri-
nate, cinnarizine and transdermal scopolamine on performance. J
Psychopharmacol 2001; 15(3): 167–72.
4. Gil A, Nachum Z, Tal D, Shupak A: A comparison of cinnarizine and
transdermal scopolamine for the prevention of seasickness in naval crew:
a double-blind, randomized, cross-over study. Clin Neuropharmacol
2012; 35(1): 37–9.
5. American Society of Aerospace Medicine Specialists: Clinical Practice
Guideline for Motion Sickness. Updated November 14, 2011. Avail-
able at http://www.asams.org/guidelines/Completed/NEW%20Motion%
20Sickness.htm; accessed December 10, 2016.
6. Leaflet 5-19 Annex B Use of anti-emetics for motion sickness. Royal
Air Force Manual: Assessment of Medical Fitness. Leaflet 5-16: Drugs
and Aircrew. Published June 27, 2016.
e1849
 Sea Sickness in Flight Crews
7. U.S. Army Aeromedical Policy Letters. Revised May 28, 2014. Motion
Sickness Policy. Revised March 15, 1997. Available at http://glwach
.amedd.army.mil/victoryclinic/documents/Army_APLs_28may2014.pdf;
accessed December 10, 2016.
8. The U.S. Navy Aeromedical Reference and Waiver Guide April
19, 2016. Available at http://www.med.navy.mil/sites/nmotc/nami/arwg/
Documents/WaiverGuide/Complete_Waiver_Guide.pdf; accessed December
10, 2016.
9. Benson AJ: Transdermal Scopolamine: A Review. Institute of Aviation
Medicine Report No 695. July 1990. RAF Farnborough.
10. Klocker N, Hanschke W, Toussaint S, Verse T: Scopolamine nasal
spray in motion sickness: a randomised, controlled, and crossover study
for the comparison of two scopolamine nasal sprays with oral dimen-
hydrinate and placebo. Eur J Pharm Sci 2001; 13(2): 227–32.
11. Makowski AL, Lindgren K, Locke JP: Visual side effects of scopol-
amine/dextroamphetamine among parabolic fliers. Aviat Space Environ
Med 2011; 82(7): 683–8.
12. Nicholson AN, Stone BM, Turner C, Mills SL: Central effects of
cinnarizine: restricted use in aircrew. Aviat Space Environ Med 2002;
73(6): 570–4.
13. Parrott AC, Golding JF: The Effect of Single and Repeated doses of
Oral Scopolamine, Cinnarizine, and Placebo, upon Psychological Per-
formance and Physiological Functioning. Institute of Naval Medicine.
Alverstoke HANTS Report 10/87 1989.
14. Schmedtje JF Jr, Oman CM, Letz R, Baker EL: Effects of scopolamine
and dextroamphetamine on human performance. Aviat Space Environ
Med 1988; 59(5): 407–10.
15. Simpson A: Drug points: bilateral scopolamine mydriasis in a traveller.
Br Med J 1987; 294: 775–6.
16. Spinks A, Wasiak J: Scopolamine for preventing and treating motion
sickness. Cochrane Database Syst Rev 2011; 6: CD002851.
17. Estrada A, LeDuc PA, Curry IP, Phelps SE, Fuller DR: Airsickness
prevention in helicopter passengers. Aviat Space Environ Med 2007;
78(4): 408–13.
18. Wood C: Pharmacologic countermeasures against motion sickness. In:
Motion and Space Sickness, pp 347. Edited by Crampton GH. Boca
Raton, FL, CRC Press, 1990.
19. Wood CD, Graybiel A: Evaluation of sixteen anti-motion sickness drugs
under controlled laboratory conditions. Aerosp Med 1968; 39: 1341–4.
e1850
20. Wood CD, Manno JE, Manno BR, et al: Evaluation of antimotion sick-
ness drug side effects on performance. Aviat Space Environ Med 1985;
56: 310–6.
Downloaded from https://academic.oup.com/milmed/article/182/11-12/e1846/4661611 by The University of North Carolina at Chapel Hill Libraries user on 26 February 2021
21. Eugene Ely Makes Naval Aviation’s First Shipboard Launch.
Smithsonian Air and Space Museum [Internet]. 2014 November [cited
November 14, 2014]. Available at http://www.navalaviationmuseum.org/
uncategorized/eugen-ely-makes-naval-aviations-first-shipboard-launch/;
accessed April 4, 2017.
22. Warwick-Evans LA1, Symons N, Fitch T, Burrows L: Evaluating sen-
sory conflict and postural instability. Theories of motion sickness. Brain
Res Bull 1998; 47(5): 465–9.
23. Zhang LL, Wang JQ, Qi RR, Pan LL, et al: Motion sickness: Current
knowledge and recent advance. CNS Neurosci Ther 2016; 22(1):
15–24.
24. Civil Aviation Authority. Available at https://www.caa.co.uk/
Aeromedical-Examiners/Medical-standards/Pilots-(EASA)/Conditions/
Gastrointestinal/Medication-used-in-GI-conditions/; accessed December
10, 2016.
25. Haasler T, Homann G, Duong Dinh TA, Jüngling E, Westhofen M,
Lückhoff A: FAA 2016 Guide for Aviation Medical Examiners. Last update
September 28, 2016. Available at https://www.faa.gov/about/office_org/
headquarters_offices/avs/offices/aam/ame/guide/media/guide.pdf; accessed
December 10, 2016.
26. Haasler T, Homann G, Duong Dinh TA, et al: Pharmacological modula-
tion of transmitter release by inhibition of pressure-dependent potassium
currents in vestibular hair cells. Naunyn Schmiedebergs Arch Pharmacol
2009; 380(6): 531–8.
27. Brainard A, Gresham C: Prevention and treatment of motion sickness.
Am Fam Physician 2014; 90(1): 41–6.
28. Transderm Scop: Package Insert and Label Information. Revised
November 16, 2016. Available at http://druginserts.com/lib/rx/meds/
transderm-scop-3/; accessed December 19, 2016.
29. Rapport JL, Buchsbaum MS, Weingartner H, Zahn TP, Ludlow C,
Mikkelsen EJ: Dextroamphetamine: its cognitive and behavioural
effects in normal and hyperactive boys and normal men. Arch Gen Psy-
chiatry 1980; 37: 933–43.
30. Zhang LL, Liu HQ, Yu XH, et al: The combination of scopolamine and
psychostimulants for the prevention of severe motion sickness. CNS
Neurosci Ther 2016; 22(8): 715–22.
MILITARY MEDICINE, Vol. 182, November/December 2017