From the Guidelines
Abdominal migraine should be diagnosed through a careful clinical history and treated with acute management using NSAIDs, such as ibuprofen or naproxen, and preventive strategies, including lifestyle modifications and medications like propranolol or amitriptyline, as these approaches prioritize reducing morbidity, mortality, and improving quality of life. When diagnosing abdominal migraine, it is essential to rule out other causes of recurrent abdominal pain and identify at least five episodes of abdominal pain lasting 2-72 hours, with pain that is midline, periumbilical, or poorly localized, along with at least two associated symptoms such as anorexia, nausea, vomiting, headache, photophobia, or pallor 1. For acute episodes, treatment may involve NSAIDs, and according to the American College of Physicians guideline, choice of a specific NSAID should be based on individualized decision making, taking into consideration patient preferences on such factors as route of administration and cost 1. Some key points to consider in the treatment of abdominal migraine include:
- Using NSAIDs like ibuprofen or naproxen for acute episodes
- Considering sumatriptan for severe attacks, although this is more commonly used for headache migraines, the principle may apply to abdominal migraine given the shared pathophysiology
- Managing associated nausea with ondansetron
- Implementing preventive strategies, including lifestyle modifications and medications, for frequent or disabling cases
- Maintaining a symptom diary to identify triggers and evaluate treatment effectiveness Given the potential for medication overuse headache, it is crucial to counsel patients to begin treatment of migraine headache as soon as possible after its onset and to be aware of the risks of overusing medications 1. Lifestyle modifications are also crucial and include regular sleep patterns, meals, hydration, stress management, and identifying food triggers like chocolate, caffeine, and processed foods. The pathophysiology of abdominal migraine is believed to involve abnormal serotonin metabolism and cortical spreading depression affecting the gut via the brain-gut axis, similar to headache migraines, which supports the use of similar treatment approaches 1.
From the Research
Diagnosis of Abdominal Migraine
- Abdominal migraine is a clinical diagnosis, with diagnostic criteria outlined under the Rome IV criteria and the International Classification of Headache Disorders III criteria 2
- It is characterized by recurrent stereotypic episodes of paroxysmal abdominal pain and nausea and/or vomiting with wellness between episodes 3
- A skilled emergency physician should always consider abdominal migraine in the differential diagnosis of patients admitted to the ED with abdominal pain, especially when the attacks are recurrent and no alternative diagnosis can be clearly established 4
Treatment of Abdominal Migraine
- Patients with abdominal migraine may benefit from prophylactic treatment with propranolol or cyproheptadine 3
- Topiramate has also been shown to be effective in relieving symptoms of abdominal migraine in adults 5
- Treatment is focused on preventive measures and mostly includes nonpharmacologic approaches, with possible pharmacologic treatments including abortive medications used for migraine headaches such as analgesics and antiemetics 2
- The current suggested management of abdominal migraine includes recognition of the condition, establishment of an appropriate diagnosis, and prevention 6
Key Characteristics
- Abdominal migraine is often associated with a positive family history of migraine and no other apparent underlying disease 3
- It consists of paroxysmal, recurrent, and acute abdominal pain attacks with associated symptoms, including pallor, nausea, vomiting, anorexia, headache, and photophobia 2
- Hypothesized contributors to its pathophysiology include a combination of visceral hypersensitivity, gut-brain enteric nervous system alterations, and psychological factors 2