Management of Abdominal Migraine
The management of abdominal migraine should follow a stepped care approach, starting with NSAIDs as first-line therapy for acute attacks, followed by triptans for unresponsive cases, and preventive therapy with propranolol or topiramate for frequent episodes. 1, 2
Diagnosis and Clinical Features
Abdominal migraine is characterized by:
- Recurrent episodes of severe, poorly localized periumbilical abdominal pain
- Pain typically lasting 1-72 hours
- Associated symptoms including nausea, vomiting, anorexia, and pallor
- Complete wellness between episodes
- Often a positive family history of migraine headaches
- More common in children (1-4%), but can occur in adults 2, 3
Acute Treatment Strategy
First-Line Treatment
- NSAIDs (ibuprofen, naproxen sodium, diclofenac potassium) 1
- Dosage should be appropriate for body weight in children
- Add antiemetic if significant nausea/vomiting is present
Second-Line Treatment
- Triptans for attacks that don't respond to NSAIDs 1, 2
- Sumatriptan (including nasal formulation for children) has shown efficacy
- Use non-oral routes when nausea/vomiting is prominent
Third-Line Treatment
- Consider rescue medications (opioids, butorphanol) only when other treatments fail and risk of abuse has been addressed 1
Preventive Treatment
Preventive therapy should be considered when:
- Attacks occur ≥2 times per month with significant disability 1
- Acute treatments are ineffective or contraindicated
- Medication overuse is a concern
First-Line Preventive Options
- Beta-blockers: Propranolol has shown excellent response (75%) in pediatric studies 4
- Topiramate: Effective in adult cases of abdominal migraine 5
- Candesartan 1
Second-Line Preventive Options
- Cyproheptadine: Particularly useful in children 2, 4
- Amitriptyline: Especially beneficial when comorbid depression or sleep disturbances exist 1
- Flunarizine (where available) 1
Duration of Preventive Treatment
- Typically 6 months to 3 years, with consideration for tapering after a period of stability 4
- Start with low doses and titrate slowly to achieve clinical benefit while minimizing adverse effects 1
Lifestyle Modifications
Identify and avoid trigger factors:
- Dietary triggers (caffeine, tyramine, nitrates)
- Stress and fatigue
- Poor sleep quality
- Environmental factors (perfumes, fumes, flickering lights) 1
Track attacks with a headache diary to identify patterns and triggers 1
Special Considerations
Children and Adolescents
- Ibuprofen is the recommended first-line medication for acute attacks 1
- Bed rest alone may suffice for short-duration attacks
- Involve family members and teachers in management 1
Adults
- Consider abdominal migraine in adults with recurrent abdominal pain when gastrointestinal workup is normal 5, 6
- Family history of migraine is often present
- Topiramate has shown good results in adult cases 5
Common Pitfalls
- Failure to consider abdominal migraine in adults with unexplained abdominal pain
- Overuse of acute medications leading to medication-overuse headaches
- Not addressing comorbid conditions (anxiety, depression, sleep disturbances)
- Inadequate duration of preventive therapy trial (benefits may take 2-3 months to manifest) 1
- Failure to recognize and modify risk factors for transformation to chronic migraine 1
By following this stepped approach to management, most patients with abdominal migraine can achieve significant improvement in symptoms and quality of life.