What is the treatment for abdominal migraine?

Treatment of Abdominal Migraine

The treatment of abdominal migraine should follow a stepwise approach with NSAIDs as first-line therapy for acute attacks, followed by triptans if NSAIDs fail, while prophylactic treatment with propranolol or topiramate should be considered for frequent or severe episodes. 1

Acute Treatment

First-Line Options:

• NSAIDs:
  • Ibuprofen 400-600mg 1, 2
  • Naproxen sodium 500-550mg 1
  • These medications are recommended for mild to moderate attacks 2

Second-Line Options:

• Triptans:
  • Sumatriptan 50mg orally (for moderate to severe attacks) 1, 2
  • Rizatriptan 10mg orally (for adolescents weighing ≥40kg) 1
  • Consider sumatriptan 6mg subcutaneously for severe attacks or significant nausea/vomiting 1

Combination Therapy:

• Sumatriptan plus naproxen has shown superior efficacy compared to either medication alone 3
• This combination is particularly effective when taken early in an attack 3

Antiemetics:

• Should be considered even if vomiting is not present, as nausea itself can be disabling 1

Prophylactic Treatment

Prophylactic treatment should be considered for patients with:

• ≥2 attacks per month with significant disability
• Failure of or contraindication to acute treatments
• Use of abortive medications more than twice weekly 1

First-Line Prophylactic Options:

• Beta-blockers:

  • Propranolol has shown excellent response (75% of patients) in abdominal migraine 4
  • Typically continued for 6 months or until cycles have stopped 4

• Anticonvulsants:

  • Topiramate has demonstrated effectiveness in adults with abdominal migraine 5
  • Typically dosed at 50mg twice daily 5

Alternative Prophylactic Options:

• Antihistamines:
  • Cyproheptadine has shown fair to excellent response in 83% of pediatric patients 4
  • May be particularly useful in younger children

Non-Pharmacological Management

• Identification and avoidance of triggers 1, 6
• Regular sleep schedule 1
• Adequate hydration 1
• Regular aerobic exercise 1
• Relaxation techniques or mindfulness 1
• Tracking symptoms using a headache/abdominal pain diary 1

Important Considerations

Medication Limitations:

• Limit triptan use to no more than 9 days per month 1
• NSAIDs should be limited to no more than 15 days per month 1
• OTC medications should be limited to no more than 14 days per month 1

Treatment Duration:

• Prophylactic treatment typically continues for 6 months to 3 years, depending on response 4
• Some patients may require shorter courses (less than 6 months) 4

Diagnostic Considerations:

• Abdominal migraine should be considered in patients with recurrent abdominal pain when gastrointestinal workup is normal 5, 6
• Family history of migraine is common and supports the diagnosis 5, 6
• Between episodes, patients typically return to baseline health 6

Pitfalls to Avoid:

• Failing to consider abdominal migraine in adults with unexplained recurrent abdominal pain 5
• Delaying treatment initiation, as early intervention in an attack provides better outcomes 3
• Overlooking the importance of prophylactic treatment in patients with frequent attacks 4, 5
• Not recognizing that abdominal migraine significantly impacts quality of life 6