Nausea and vomiting are among the most common reasons people visit a community pharmacy, but the over-the-counter armoury for symptomatic relief is narrower than many patients expect. The MHRA has tightened the supply route for several anti-emetics over the past decade, and pharmacists need to be confident about what is genuinely available without prescription, what is restricted to short-term use, and when self-management has reached its limit.

This guide reviews the anti-emetics that can be supplied in the UK without prescription, the conditions where they help, and the safety considerations that should be discussed at the counter. It draws on the BNF, the MHRA Drug Safety Update bulletins on domperidone and metoclopramide, and the NICE Clinical Knowledge Summaries on nausea and vomiting in adults and in pregnancy.

What is available without a prescription

Medicine	Pharmacy supply	Typical indications
Cyclizine 50 mg	Pharmacy (P) — Valoid and own-label	Motion sickness, vestibular nausea (12+ years)
Promethazine teoclate 25 mg (Avomine)	P	Motion sickness (5+ years)
Promethazine hydrochloride 25 mg (Phenergan)	P	Sedation; off-label nausea use
Hyoscine hydrobromide 150 microgram (Joy-Rides, Kwells Kids)	P	Motion sickness in children 4+
Hyoscine hydrobromide 300 microgram (Kwells, Travel Calm)	P	Adult motion sickness
Prochlorperazine 3 mg buccal tablets (Buccastem M)	P	Nausea associated with previously diagnosed migraine
Ginger lozenges, capsules	GSL / P	General nausea, pregnancy nausea

Domperidone has been prescription-only in the UK since 2014 because of dose-related cardiac risks. Metoclopramide has long been prescription-only. Ondansetron and other 5HT3 antagonists are prescription-only.

Cyclizine

Cyclizine is a first-generation H1 antihistamine with anticholinergic and weak antimuscarinic activity. It is the most commonly purchased OTC anti-emetic in the UK.

Indications:

• Motion sickness prophylaxis and treatment
• Labyrinthine and vestibular nausea
• Inner-ear-related vertigo

Counselling:

• Onset 30–60 minutes; take 1–2 hours before travel
• Repeat dose 4–6 hourly; max 200 mg/day
• Sedating; warn about driving and operating machinery
• Avoid alcohol
• Anticholinergic effects: dry mouth, urinary retention, blurred vision
• Caution in glaucoma, prostatic enlargement, severe heart failure, epilepsy
• Avoid in children under 12 (manufacturer SPC)

Pregnancy: the BNF advises avoiding cyclizine where possible, though it is sometimes used off-label for hyperemesis gravidarum under specialist care.

Promethazine

Two salts are used:

• Promethazine hydrochloride (Phenergan, Sominex) — primary indication is short-term insomnia and allergy; nausea use is off-label
• Promethazine teoclate (Avomine) — licensed specifically for motion sickness from age 5

Both are sedating long-acting H1 antihistamines.

Counselling:

• Promethazine teoclate (Avomine): one tablet the night before travel for prophylaxis; one tablet morning of travel for short trips
• Strongly sedating; avoid in patients who need to drive or operate machinery
• Caution in older adults — risk of confusion, falls, urinary retention
• Avoid in children under 2 (respiratory depression risk)
• Pregnancy: promethazine has the most extensive safety record of the OTC anti-emetics and is used (under medical supervision) for nausea and vomiting in pregnancy when first-line measures fail

Prochlorperazine 3 mg buccal (Buccastem M)

Prochlorperazine 3 mg buccal is a unique OTC option for migraine-associated nausea. The buccal route bypasses the gastric absorption that is impaired during a migraine attack.

Restrictions on OTC supply:

• Adults aged 18 and over only
• Patient must have a previously diagnosed migraine (not first presentation)
• Maximum two days continuous use
• Caution in liver disease, Parkinson's disease and elderly patients
• Avoid in pregnancy (use in pregnancy is a prescriber decision under specialist care)

Counselling:

• Place between upper gum and lip; allow to dissolve over 1–2 hours
• Do not chew or swallow
• Sedation likely; alcohol should be avoided
• Patient should review with GP if migraines are not controlled

Hyoscine hydrobromide

A muscarinic antagonist used for motion sickness. Available as Kwells (300 mcg) and child formulations (150 mcg, Joy-Rides, Kwells Kids). Onset 20–30 minutes; duration 4–8 hours. Side effects: drowsiness, dry mouth, blurred vision, urinary retention. Avoid in glaucoma, prostatic enlargement, intestinal obstruction.

A transdermal patch (Scopoderm 1.5 mg) is also available as a P medicine and provides 72 hours of motion sickness control. The patch is applied behind the ear several hours before travel; one patch covers a 72-hour journey, which makes it the favoured option for long ferry crossings, cruises and trans-oceanic flights.

Ginger and other non-pharmacological options

Ginger 0.5–1.5 g per day in divided doses has limited but consistent evidence for pregnancy nausea (NICE CKS recommends as a self-care option) and for chemotherapy-induced nausea (under specialist supervision). The mechanism is incompletely understood; it appears safe at culinary doses in pregnancy.

Acupressure wristbands (Sea-Band) target the P6 acupoint. Cochrane evidence is mixed; the bands are inexpensive, free of side effects and can be combined with pharmacological options.

Hydration, small frequent meals, ginger biscuits and avoidance of trigger smells form the first line in pregnancy and many self-limiting nausea episodes.

Pregnancy and breastfeeding

Pregnancy nausea (often termed nausea and vomiting in pregnancy, NVP) affects up to 80% of pregnancies. Mild cases respond to dietary measures and ginger. Where pharmacological treatment is needed, the RCOG green-top guideline favours doxylamine/pyridoxine (Xonvea) — prescription-only — first line. Cyclizine and promethazine are second-line, used on prescription with patient counselling about the available evidence.

Severe cases meeting hyperemesis gravidarum criteria (more than 5% weight loss, dehydration, electrolyte disturbance) require urgent referral. The pharmacist's role is to recognise red flags (inability to keep fluid down for 24 hours, dark urine, ketosis, abdominal pain, fever) and signpost to maternity assessment.

Children

OTC anti-emetics in children are largely limited to motion sickness:

• Hyoscine 150 microgram from age 4 (Kwells Kids, Joy-Rides)
• Promethazine teoclate (Avomine) from age 5
• Cyclizine generally avoided under age 12

Acute vomiting in young children — particularly under 2 years — is usually viral gastroenteritis, where rehydration with oral rehydration salts (Dioralyte) is first-line. Persistent vomiting in a young child is a referral, not an OTC sale.

Red flags for referral

• Vomiting blood or coffee-ground material — A&E
• Vomiting with severe abdominal pain — same day GP / 111
• Vomiting in a child under 2 with reduced alertness or fewer wet nappies — same day
• Vomiting after head injury — A&E
• Persistent vomiting more than 48 hours in adults; 24 hours in children
• Pregnancy vomiting with weight loss, ketosis or dehydration — maternity assessment
• New onset of severe morning vomiting suggesting raised intracranial pressure — same day
• Vomiting with ketotic breath in a known diabetic — A&E (DKA)

A counselling structure

A focused 90-second consultation usually clarifies the right product:

1. What is the situation? (travel, migraine, post-meal, pregnancy, gastroenteritis)
2. Age and weight
3. Other medicines and conditions (glaucoma, prostate, epilepsy, Parkinson's)
4. Pregnancy and breastfeeding status
5. Any red flags
6. Tolerance for sedation

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Sources

• BNF — Antiemetics
• NICE Clinical Knowledge Summary: Nausea/vomiting in adults
• NICE Clinical Knowledge Summary: Nausea/vomiting in pregnancy
• MHRA Drug Safety Update — Domperidone (2014) and Metoclopramide (2014)
• Royal College of Obstetricians and Gynaecologists — Green-top Guideline 69: Management of NVP and HG
• Summary of Product Characteristics for Buccastem M, Avomine, Kwells, Cyclizine 50 mg