What is the management of abdominal migraine?

Management of Abdominal Migraine

NSAIDs are the first-line treatment for acute attacks of abdominal migraine, while prophylactic therapy with propranolol or topiramate should be initiated for patients experiencing recurrent episodes. 1, 2, 3

Diagnosis and Clinical Features

Abdominal migraine is characterized by:

• Recurrent stereotypic episodes of paroxysmal periumbilical abdominal pain
• Pain typically lasts 1 or more hours
• Associated symptoms: nausea, vomiting, pallor, anorexia
• Wellness between episodes
• Often positive family history of migraine
• More common in children (1-4%), particularly girls aged 7-12 years, but can occur in adults

Acute Management

First-Line Treatment:

• NSAIDs (ibuprofen, naproxen sodium, aspirin) 1
  • Dosage should be appropriate for body weight in children
  • For adults, standard anti-migraine dosing applies

Second-Line Treatment:

• Triptans for patients who don't respond to NSAIDs 1
  • Sumatriptan (including nasal formulation) has shown efficacy 4
  • Consider non-oral routes if significant nausea/vomiting is present

Antiemetics:

• Add antiemetic medication when nausea/vomiting is prominent 1
  • Domperidone may be used for adolescents aged 12-17 years 1

Prophylactic Treatment

Indications for preventive therapy:

• Two or more attacks per month
• Attacks causing disability for three or more days per month
• Use of rescue medication more than twice a week
• Failure of acute treatments 1

First-Line Prophylactic Options:

• Propranolol (80-240 mg/day for adults, weight-appropriate for children) 1, 2, 4
  • 75% of pediatric patients show excellent response 2
• Topiramate (50 mg twice daily for adults) 3
  • Particularly effective in adult cases

Alternative Prophylactic Options:

• Cyproheptadine (particularly in children) 2, 4
  • 33% excellent response, 50% fair response in pediatric patients 2
• Beta blockers (other than propranolol) 1, 3
• Calcium channel blockers (flunarizine where available) 1, 3

Duration of Prophylactic Treatment

• Typically continue medication for at least 6 months 2
• Consider tapering or discontinuing after a period of stability 1
• Some patients may require treatment for up to 3 years 2

Non-Pharmacological Management

• Identify and avoid trigger factors:
  • Common triggers: stress, fatigue, poor sleep quality
  • Dietary triggers: caffeine, foods containing tyramine or nitrates 1
• Lifestyle modifications to improve sleep quality and physical fitness 1

Special Considerations

• For adult patients with suspected abdominal migraine:
  • Ensure comprehensive gastrointestinal workup with normal results before diagnosis 3, 5
  • Consider family history of migraine as supporting evidence 3
  • Topiramate is particularly recommended for adult cases 3

Common Pitfalls

• Failure to consider abdominal migraine in adults with unexplained recurrent abdominal pain
• Overemphasis on identifying triggers rather than initiating effective treatment
• Inadequate duration of prophylactic therapy (stopping before 6 months)
• Not considering medication overuse, which can worsen the condition
• Failing to use non-oral routes of administration when nausea/vomiting is prominent

Abdominal migraine, though more common in children, should be considered in the differential diagnosis for adults with recurrent abdominal pain when other gastrointestinal pathologies have been excluded. Early recognition and appropriate management can significantly improve quality of life and reduce morbidity associated with this condition.