What is an abdominal migraine?

Abdominal Migraine: Diagnosis and Management

Abdominal migraine is a functional disorder characterized by recurrent episodes of moderate to severe paroxysmal abdominal pain, often accompanied by nausea, vomiting, pallor, and anorexia, with complete wellness between episodes. 1, 2

Clinical Presentation

• Recurrent, stereotypic episodes of paroxysmal abdominal pain typically lasting 1-72 hours 3
• Associated symptoms include pallor, nausea, vomiting, anorexia, and sometimes headache and photophobia 2
• Complete return to baseline health between episodes 1
• More commonly diagnosed in children but can also occur in adults 4
• Often associated with a positive family history of migraine 5

Diagnostic Criteria

Abdominal migraine is diagnosed using established clinical criteria:

• According to the International Classification of Headache Disorders (ICHD) criteria, abdominal migraine is characterized by idiopathic attacks of midline, moderate to severe abdominal pain lasting 1-72 hours with vasomotor symptoms, nausea, and vomiting 3
• The Rome IV criteria (gastroenterology) also recognize abdominal migraine as a well-defined cause of recurrent abdominal pain 3
• Diagnosis requires exclusion of anatomic, infectious, inflammatory, or metabolic causes 3

Pathophysiology

• Believed to share pathophysiological mechanisms with migraine headaches 1
• Hypothesized contributors include:
  • Visceral hypersensitivity 2
  • Gut-brain enteric nervous system alterations 2
  • Psychological factors 2
• Often considered a "migraine equivalent" or precursor to typical migraine headaches 1, 3

Epidemiology

• Affects approximately 0.2% to 4.1% of children 2
• Represents about 4-15% of children with chronic, idiopathic, recurrent abdominal pain 3
• More common in females than males, similar to the gender distribution seen in migraine headaches 3
• Children with abdominal migraine often develop typical migraine headaches as they grow older 1

Management

Non-pharmacological Approaches

• Identification and avoidance of potential triggers 2
• Maintaining regular sleep patterns 2
• Stress management techniques 2

Pharmacological Treatment

Acute Treatment

• Analgesics and antiemetics may be used for symptom relief during acute attacks 2

Preventive Treatment

• Propranolol has shown excellent response in 75% of treated children in clinical studies 5
• Cyproheptadine has shown excellent response in 33% of treated children and fair response in 50% 5
• Treatment duration typically ranges from 6 months to 3 years 5

Clinical Implications

• Abdominal migraine is likely underdiagnosed, particularly in the United States 3
• Patients with abdominal migraine report lower quality of life, making proper diagnosis and treatment important 2
• Increased awareness among clinicians may result in improved diagnostic accuracy and early institution of both acute and preventative migraine-specific treatments 3
• Special consideration should be given to patients with abdominal migraine undergoing surgical procedures, as opioids may trigger attacks in susceptible individuals 4

Common Pitfalls

• Failure to consider abdominal migraine in the differential diagnosis of recurrent abdominal pain, leading to unnecessary diagnostic testing 3
• Misdiagnosis as "functional abdominal pain" without specific categorization 3
• Inadequate treatment due to lack of recognition of the condition 3
• Not considering the condition in adults, as it's often thought of as primarily a pediatric disorder 4