What are the treatment options for abdominal migraines?

Treatment Options for Abdominal Migraines

NSAIDs should be used as first-line treatment for abdominal migraines, followed by triptans as second-line therapy if NSAIDs are ineffective, with prophylactic medications like propranolol or topiramate recommended for frequent episodes. 1, 2

Acute Treatment Options

First-Line Treatment

• NSAIDs (aspirin, ibuprofen, naproxen sodium, diclofenac potassium) are recommended as first-line therapy for abdominal migraines 1, 2
• Treatment should begin as early as possible during an attack for maximum efficacy 1, 2
• Acetaminophen may be used, but is generally less effective than NSAIDs for migraine symptoms 1, 2

Second-Line Treatment

• Triptans (sumatriptan, rizatriptan, naratriptan, zolmitriptan) should be added to NSAIDs or acetaminophen if first-line treatments are ineffective 1, 2
• For patients with severe nausea or vomiting (common in abdominal migraines), consider non-oral triptans and antiemetics 1, 2
• Prokinetic antiemetics such as domperidone and metoclopramide are useful adjuncts for managing nausea and vomiting during attacks 1

Third-Line Treatment

• CGRP antagonists-gepants (rimegepant, ubrogepant, zavegepant) or dihydroergotamine may be considered for patients who don't respond to combination therapy of triptans with NSAIDs or acetaminophen 1, 2
• Lasmiditan (ditan) can be considered for patients who don't tolerate or have inadequate response to all other pharmacologic treatments 1

Prophylactic Treatment

• Propranolol is FDA-approved for migraine prophylaxis and has shown efficacy in preventing abdominal migraine attacks 3, 4
• Topiramate has demonstrated effectiveness as prophylactic therapy for abdominal migraines in adults with recurrent, severe abdominal pain 5
• Cyproheptadine may be effective as prophylactic treatment, though it appears less effective than propranolol 4
• Prophylactic treatment should be considered when abdominal migraines occur frequently (≥2 days per month) or significantly impair quality of life despite optimized acute therapy 1

Important Considerations and Cautions

• Avoid opioids and butalbital-containing medications for abdominal migraines due to questionable efficacy, adverse effects, and risk of dependency 1, 2, 6
• Be aware of medication overuse headache risk when acute treatments are used too frequently (≥15 days/month with NSAIDs or ≥10 days/month with triptans) 1, 2
• Abdominal migraine should be considered when patients have recurrent abdominal pain with normal gastrointestinal workup results, especially with a family history of migraine 5
• For patients with known abdominal migraines triggered by opioids, an opioid-sparing treatment plan should be implemented if they require surgery 7

Lifestyle Modifications

• Counsel patients on important lifestyle modifications that may help reduce frequency and severity of abdominal migraine attacks 1, 2:
  • Maintaining adequate hydration
  • Regular meals
  • Sufficient and consistent sleep
  • Regular physical activity
  • Stress management techniques
  • Weight loss if overweight or obese

Treatment Algorithm

1. Start with NSAIDs at appropriate dosage for acute attacks
2. If inadequate relief, add a triptan to the NSAID regimen
3. For patients with significant nausea/vomiting, add an antiemetic
4. For patients not responding to above treatments, consider CGRP antagonists or dihydroergotamine
5. For patients with frequent attacks (≥2 per month), initiate prophylactic therapy with propranolol or topiramate
6. Evaluate prophylactic therapy effectiveness after 2-3 months; if ineffective, try an alternative prophylactic medication 1