What is the recommended treatment for abdominal migraine?

Treatment for Abdominal Migraine

For abdominal migraine, propranolol is recommended as first-line prophylactic treatment, with cyproheptadine as an alternative option. 1

Acute Treatment Options

For acute episodes of abdominal migraine, follow a step-wise approach:

1. First-line treatments for mild to moderate attacks:

   • NSAIDs (such as ibuprofen or naproxen)
   • Acetaminophen
   • Combination of NSAID + acetaminophen 2, 3

2. For moderate to severe attacks:

   • Triptan + NSAID combination
   • Triptan + acetaminophen (if NSAIDs are contraindicated) 3

3. For attacks with significant nausea or vomiting:

   • Non-oral triptan formulation (nasal spray, injection) + antiemetic 2, 3

Prophylactic Treatment

Prophylactic treatment should be considered when:

• Episodes occur ≥2 times per month
• Attacks are prolonged and disabling
• Poor response to acute treatments
• Quality of life is reduced between attacks 4

First-line prophylactic options:

1. Propranolol:

   • Dosage: 80-240 mg/day
   • Shown to be highly effective with 75% of patients having excellent response 1, 3
   • FDA-approved for migraine prophylaxis 5

2. Cyproheptadine:

   • Alternative option with 33% excellent response and 50% fair response 1
   • Particularly useful in children and young adults

3. Other effective options:

   • Topiramate (100 mg/day) 6, 3
   • Amitriptyline (30-150 mg/day)
   • Flunarizine 3, 7

Treatment Duration and Monitoring

• Continue prophylactic medication for at least 6 months 1
• Use a headache/symptom diary to track frequency and response
• Evaluate response after 2-3 months of treatment
• If first prophylactic medication fails after adequate trial (6-8 weeks), switch to another agent 3

Important Considerations

• Avoid opioids and butalbital for treatment of abdominal migraine due to risk of medication overuse 2, 3, 8
• Limit acute medications to ≤10 days/month for triptans and ≤15 days/month for NSAIDs to reduce risk of medication overuse 3
• Begin treatment as early as possible during an attack for better efficacy 2
• Consider comorbidities when selecting medications:
  • Beta-blockers may benefit patients with hypertension
  • Amitriptyline may help those with comorbid tension headaches or depression 3

Lifestyle Modifications

Implement the following lifestyle changes to help reduce frequency and severity of attacks:

• Maintain regular sleep schedule
• Stay well hydrated
• Identify and avoid personal triggers using a symptom diary
• Regular physical activity
• Stress management techniques 3

When to Suspect Abdominal Migraine

Abdominal migraine should be considered when:

• Recurrent stereotypic episodes of paroxysmal abdominal pain
• Associated nausea and/or vomiting
• Wellness between episodes
• Family history of migraine
• Normal gastrointestinal workup 1, 6

Abdominal migraine is often overlooked in adults but should be considered as a possible diagnosis when patients have recurrent abdominal pain with normal gastrointestinal workup, especially with a family history of migraine 6.