Management of Abdominal Migraine in Adults with Childhood History
For adults with abdominal migraine and a history of childhood abdominal migraine, a stepped care approach using migraine prophylactic medications is recommended, with topiramate as the first-line agent for prevention. 1
Diagnosis and Clinical Features
- Abdominal migraine in adults presents as recurrent episodes of severe abdominal pain with migrainous features including nausea, vomiting, pallor, and vasomotor symptoms 2
- Episodes are typically stereotyped, unprovoked, and patients feel normal between attacks 2
- Anxiety-like symptoms may occur as part of the prodrome 2
- Diagnosis should be considered after a complete gastrointestinal workup with normal results in patients with a history of childhood migraines or family history of migraines 1, 2
First-Line Management
Acute Treatment
- NSAIDs with antiemetics as needed for breakthrough episodes 3
- Sumatriptan (particularly nasal formulations) may be effective for acute relief of abdominal migraine attacks 4, 2
- Avoid opioids as they may trigger abdominal migraine in susceptible individuals 5
Prophylactic Treatment
- Topiramate (50 mg twice daily) is recommended as first-line prophylactic therapy for adults with abdominal migraine 1
- Consider prophylactic treatment when patients are adversely affected on ≥2 days per month despite optimized acute treatment 3
Second-Line Options
- Beta-blockers (propranolol, metoprolol) are effective second-line prophylactic options 4, 3
- Calcium channel blockers (flunarizine, pizotifen) have shown efficacy in case reports 6, 4
- Amitriptyline can be considered, particularly when there are comorbid sleep disturbances 3, 7
- Candesartan is another option with evidence for migraine prophylaxis 3
Non-Pharmacological Approaches
- Maintain a headache/abdominal pain diary to identify triggers and monitor treatment effectiveness 3, 7
- Implement lifestyle modifications including regular meals, consistent sleep patterns, stress management, and hydration 8
- Consider cognitive behavioral therapy (CBT), relaxation training, or biofeedback which have shown efficacy for migraine management 3, 8
- Regular exercise (40 minutes three times weekly) has been shown to be as effective as relaxation therapy or topiramate for migraine prevention 3, 8
Monitoring and Follow-up
- Schedule regular follow-up visits to monitor frequency, severity, and response to treatment 8
- Use standardized assessment tools like the Headache Impact Test (HIT-6) to monitor progress 3
- Adjust treatment based on response and tolerability 8
- Consider discontinuing preventive medication after 3-6 months of stability to determine if prophylaxis is still needed 7
Important Considerations and Pitfalls
- Beware of medication overuse headache, which can occur with frequent use of acute medications (≥15 days/month for NSAIDs) 7
- Benefits of preventive medications may take several weeks to become apparent, so encourage adherence 7
- Consider comorbid conditions when selecting prophylactic medications 7
- Adult abdominal migraine is often misdiagnosed or overlooked, leading to unnecessary investigations and delayed treatment 2
- Inquire specifically about history of childhood migraines when faced with unexplained recurrent abdominal pain 2