Diagnosing and Managing Abdominal Migraine
Abdominal migraine should be diagnosed using established criteria including recurrent stereotypic episodes of paroxysmal abdominal pain with nausea/vomiting, wellness between episodes, and often a positive family history of migraine, with prophylactic treatment using propranolol or cyproheptadine as first-line options. 1, 2
Diagnostic Criteria for Abdominal Migraine
Abdominal migraine is an often under-diagnosed cause of recurrent abdominal pain, particularly in children but also occurring in adults. To diagnose abdominal migraine, look for:
- Recurrent stereotypic episodes of paroxysmal abdominal pain 2
- Pain typically located in the midline 3
- Episodes lasting 1-72 hours 3
- Nausea and/or vomiting during episodes 2, 3
- Complete wellness between episodes 2
- Positive family history of migraine (present in up to 90% of cases) 2, 4
- Normal findings on gastrointestinal workup 5, 4
Differential Diagnosis
Before diagnosing abdominal migraine, it's essential to rule out other causes of recurrent abdominal pain:
- Anatomic abnormalities
- Infectious causes
- Inflammatory conditions
- Metabolic disorders 3
Abdominal migraine is one of the "functional abdominal pain" diagnoses, alongside:
- Functional dyspepsia
- Irritable bowel syndrome
- Functional abdominal pain syndrome 3
Treatment Options
Prophylactic Treatment
Prophylactic treatment is the mainstay of abdominal migraine management:
First-line options:
Alternative options:
Acute Treatment
For acute episodes, some patients may respond to:
- Sumatriptan (abortive therapy) 5
- NSAIDs may be considered based on their efficacy in migraine headaches 1
Duration of Treatment
Treatment duration varies:
- Initial recommendation: Continue medication for at least 6 months 2
- In practice: Treatment duration ranges from less than 6 months to 3 years 2
Special Considerations
Adult Abdominal Migraine
- Abdominal migraine is not exclusive to children and should be considered in adults with recurrent abdominal pain 5, 4
- Adult patients often have a long history of abdominal pain refractory to conventional therapies 5
- Strong family history of migraine is common (90% in one study) 4
- Normal gastrointestinal workup findings are characteristic 5, 4
Perioperative Management
For patients with known abdominal migraine undergoing surgery:
- Consider opioid-sparing treatment plans, as opioids can trigger abdominal migraine in susceptible individuals 6
- Coordinate with anesthesia team to prevent perioperative exacerbations 6
Common Pitfalls in Diagnosis
- Underdiagnosis: Abdominal migraine is frequently under-diagnosed, with studies showing it represents 4-15% of children with chronic, idiopathic, recurrent abdominal pain 3
- Delayed diagnosis: Patients often undergo extensive and repeated gastrointestinal workups before abdominal migraine is considered 5, 3
- Failure to recognize in adults: Many clinicians incorrectly believe abdominal migraine occurs only in children 4
- Missing family history: Not inquiring about family history of migraine can lead to missed diagnoses 2, 4
By recognizing the characteristic pattern of symptoms and considering abdominal migraine in the differential diagnosis of recurrent abdominal pain, clinicians can provide appropriate treatment and improve outcomes for these patients.