Abdominal Migraine

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Abdominal migraine is a disease entity characterized by significant paroxysmal abdominal pain and nausea or vomiting.1 Despite the suggestion made by its name, no headache occurs.

Episodes of abdominal migraine alternate with periods of wellness. The disease predominantly affects children, and prevalence peaks at age 10.2

Because abdominal pain can be associated with a variety of disorders, abdominal migraine can be difficult to identify, and diagnosis is often made on the basis of exclusion.

History

The symptoms of abdominal migraine were first described as “gastric megrim” in 1873.3 In the early 1900s, the term “abdominal migraine” was introduced.4 It was described as attacks of abdominal pain, nausea, vomiting of bile and mucus, and occasional diarrhea in patients with personal or family histories of migraine headache.4 The physical examination findings for affected patients were benign.4 These attacks were episodic and had an abrupt onset and resolution.4

In 1933, Wyllie and Schlesinger described recurrent abdominal pain in children in association with abdominal migraine, and they linked the syndrome with migraine.5 In 1986, Symon and Russell reported on a group of children whom they believed had abdominal migraine due to unexplained recurrent attacks of epigastralgia.6 Cullen and MacDonald had noted the association of migraine headache with the periodic syndrome in 1963 but did not investigate it.7 Over time, it became common to think that abdominal pain in children developed into migraine headaches later in life.8

Other observers thought that cyclic vomiting syndrome, migraine headache and abdominal migraine were all part of a single clinical syndrome.9 For a time, cyclic vomiting syndrome and abdominal migraine were thought to be the same, and the names were used interchangeably. They were eventually recognized as different entities.10

Abdominal migraine was not included in the first edition of the International Classification of Headache Disorders in 1988, but it was included in the second edition in 2004.11,12 In 2006, the Rome III Functional Gastrointestinal Disorders criteria classified abdominal migraine as a cause of recurrent abdominal pain with similar but separate diagnostic criteria.13

Diagnosis

Diagnosis of abdominal migraine can be made using the International Classification of Headache Disorders criteria (Table 1)11,12 and/or the Rome III criteria (Table 2).13

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Abdominal migraine is characterized by periods of nausea, vomiting and severe midline, periumbilical or diffuse abdominal pain that lasts for several hours to days and occurs several times per year.14

Headache is not always present, but the typical patient exhibits flushing, pallor, anorexia, irritability, dark shadows around the eyes, phonophobia and photophobia.14

Most children are symptom free between attacks but are so ill during attacks that they are incapacitated and want to be left alone.1,2,11-14

Abdominal migraine is most common in children with a family history of migraine headache. It affects girls slightly more often than boys (incidence of 1.2:1), and usually occurs between ages 3 and 10, with prevalence declining thereafter.1,2,6,8,9,11,13,15

Abdominal migraine resolves spontaneously in the majority of children.8 However, some patients develop migraine headache in adulthood.8,16

The diagnosis of abdominal migraine is made based on medical history, benign physical examination findings, lack of an identified organic process, and meeting the established diagnostic criteria.17

Pathogenesis

Over the years, several hypotheses about the cause of abdominal migraine have been suggested. They include IgE-mediated diet-induced allergy, phenol sulfotransferase enzyme M and P catabolism of monoamines and catecholamines, gut mucosal immune responses, and gut mucosal surface permeability.18

The enteric nervous system and the central nervous system are derived from the same embryologic tissues, so they have direct effects on each other.19

The theory is that stress, which increases central nervous system arousal, results in the release of neuropeptides and neurotransmitters, which leads to malfunction of the gastrointestinal tract.19 This results in episodic attacks of abdominal pain.19

Despite these detailed hypotheses, the pathogenesis and pathophysiology of abdominal migraine are unknown.

Treatment

Treatment of abdominal migraine should be based on the patient’s and family’s attitude about the disease and the frequency and severity of attacks.1,2,17 The literature contains little information about treatment. As a result, clinical management is not evidence-based. Healthcare providers report treating the disorder with nonpharmacologic and pharmacologic measures.1,2,17

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Nonpharmacologic management of abdominal migraine includes education of the patient and family about the syndrome and reassuring them that no evidence of significant abdominal disease is present.1,2,17 Coping strategies should be taught to the child to help prevent and relieve both good and bad stress.1,2,17 Advise parents to make sure that children do not skip meals.

Early morning hypoglycemia can trigger an abdominal migraine, so eating a high-fiber snack at bedtime is recommended.1,2,17 Establishing and adhering to a sleep routine may also contribute to the management of symptoms.

When traveling, advise parents to take steps to minimize motion sickness, such as sitting in a spot that causes less sense of motion or making frequent stops.1,2,17 Wearing hats and sunglasses to minimize sun glare and bright lights can also be helpful.1,2,17

Some clinicians recommend a diet low in amines and monosodium glutamate, since foods such as coffee, chocolate, cola, tea, cheese and artificial food colorings may trigger an attack.1,17 A “few-foods” diet might be beneficial. This involves removing many foods from the diet and then re-introducing a food once weekly to identify triggers.1,17 Two studies suggest that abdominal migraine can be associated with food sensitivity and lactose intolerance. 23,24

Pharmacologic management of abdominal migraine is either prophylactic or abortive. Some success has been reported with propranolol, pizotifen, cyproheptadine, erythromycin, phenobarbital, clonidine, valproic acid, tricyclic antidepressants and metoclopramide.1,10,17,20-22

However, triptans and selective serotonin receptor agonists are not approved by the Food and Drug Administration for use in children and adolescents for migraine headache or abdominal migraine.1,25

Some research shows that zolmitriptan and sumatriptan nasal sprays can be effective in managing abdominal migraine in teenagers.25

For the small number of patients who experience abdominal migraine into adolescence or adulthood, these treatment options can be helpful.

More Research Needed

Abdominal migraine is an illness that should be recognized by clinicians. Diagnosis should be made based on a thorough history and physical examination along with use of published diagnostic criteria.11-13

Nurse practitioners and physician assistants should provide patient and caregiver education about the illness, trigger foods and treatment.1,2,17 Because pharmacologic treatment choices are limited, further research is needed to identify the pathogenesis and mechanisms of abdominal migraine. Drug trials focused on preventing and treating acute attacks should be undertaken.

References

1. Russell G, et al. Abdominal migraine: evidence for existence and treatment options. Paediatr Drugs. 2002;4(1):1-8.

2. Abu-Arafeh I, Russell G. Prevalence and clinical features of abdominal migraine compared with those of migraine headache. Arch Dis Child. 1995;72(5):413-417.

3. Liveing E. On Megrim, Sick-Headache, and Some Allied Disorders: A Contribution to the Pathology of Nervestorms. London, England: Churchill; 1873.

4. Brams WA. Abdominal migraine. JAMA.1922;78:26-27.

5. Wyllie WG, Schlesinger B. The periodic group of disorders in childhood. Brit J Child Dis. 1933;30:1-21.

6. Symon DNK, Russell G. Abdominal migraine: a childhood syndrome defined. Cephalalgia. 1986;6(4):223-228.

7. Cullen KJ, MacDonald WB. The periodic syndrome: its nature and prevalence. Med J Austr. 1963;50(2):167-172.

8. Dignan F, et al. The prognosis of childhood abdominal migraine. Arch Dis Child. 2001;84(5):415-418.

9. Abu-Arahef I. Childhood headache: from a minor symptom to an important area for research. In: Abu-Arahef I. Childhood Headache. Cambridge, Mass.: Mac Keith Press; 2002: 1-3.

10. Catto-Smith AG, Ranuh R. Abdominal migraine and cyclical vomiting. Semin Pediatr Surg. 2003;12(4):254-258.

11. Headache Classification Subscommittee of the International Headache Society. The International Classification of Headache Disorders. 2nd ed. Cephalalgia. 2004;24(Suppl 1):9-160.

12. Cuvellier JC, Lepine A. Childhood periodic syndromes. Pediatr Neurol.2010;42(1):1-11.

13. Rasquin A, et al. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2006;130(5):1527-1537.

14. Lewis DW. Pediatric migraine. Neurol Clin. 2009;27(2):481-501.

15. Carter JE. Abdominal migraines. In: Howard FM, et al, eds. Pelvic Pain: Diagnosis and Management. Philadelphia, PA: Lippincott Williams & Wilkins; 2000: 441-443.

16. Carson L, et al. Abdominal Migraine: an under-diagnosed cause of recurrent abdominal pain in children. Headache. 2011;51(5):707-712.

17. Popovich DM, et al. Recognizing and diagnosing abdominal migraines. J Pediatr Health Care. 2010;24(6):372-377.

18. Bentley D, et al. Abdominal migraine as a cause of vomiting in children: a clinician’s view. J Pediatr Gastroenterol Nutr. 1995;21(Suppl 1):S549-S551.

19. Weydert JA, et al. Systematic review of treatments for recurrent abdominal pain. Pediatrics. 2003;111(1);e1-e11.

20. Barr RG, et al. Recurrent abdominal pain of childhood due to lactose intolerance. N Engl J Med. 1979;300(26):1449-1452.

21. Lubmin WM. Recurrent abdominal pain in children: lactose and sucrose intolerance, a prospective study. Pediatrics. 1979;64(1):43-45.

22. Symon DN, Russell G. Double blind placebo controlled trial of pizotifen syrup in the treatment of abdominal migraine. Arch Dis Child. 1995;72(1):48-50.

23. Worawattanakul M, et al. Abdominal migraine: prophylactic treatment and follow-up. J Pediatr Gastroenterol Nutr. 1999;28(1):37-40.

24. Tan V, et al. Abdominal migraine and treatment with intravenous valproic acid. Psychosomatics. 2006;47(4):353-355.

25. Major P, et al. Triptans for the treatment of acute pediatric migraine: a systematic literature review. Pediatr Neurol. 2003;29(5):425-429.

Joanne M. Churak is a physician assistant at the Veterans Affairs Medical Center in West Haven, Conn. Melissa M. Churak is a bachelor of arts student at Fordham University in the Bronx, N.Y. The authors have completed disclosure statements and report no relationships related to this article.

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