Treatment of Abdominal Migraine

Propranolol is the first-line prophylactic treatment for abdominal migraine, with 75% of patients achieving complete cessation of symptoms. 1

Acute Treatment During Episodes

Antiemetics such as metoclopramide or prochlorperazine should be administered to control nausea and vomiting, which are cardinal features of abdominal migraine attacks 2
Analgesics including NSAIDs (ibuprofen or ketorolac) can be used for pain control during acute episodes 2, 3
Sumatriptan (abortive migraine therapy) has shown efficacy in some adult patients with abdominal migraine, particularly when attacks are severe 4
Non-oral routes of administration are preferred when significant nausea or vomiting is present 2

Propranolol is the most effective prophylactic agent, with 75% achieving excellent response (complete cessation of attacks) and an additional 8% achieving fair response (milder, less frequent symptoms) 1
Dosing follows standard migraine prophylaxis protocols: 80-160 mg oral once or twice daily in long-acting formulations 5
Treatment duration should be at least 6 months or until attack cycles have stopped, though many patients require shorter courses (46% took medication less than 6 months) 1

Cyproheptadine is an alternative prophylactic option, particularly useful in children 1, 4
Response rates are lower than propranolol: 33% excellent response and 50% fair response 1
Treatment duration ranges from 6 months to 3 years depending on response 1

Topiramate 50 mg twice daily has demonstrated efficacy in adult abdominal migraine, particularly in refractory cases 4
Calcium channel blockers (flunarizine 5-10 mg daily) have shown benefit in some patients 4
Amitriptyline 10-100 mg oral at night can be considered as second-line therapy 5

Initiate propranolol as first-line prophylactic therapy for patients with recurrent abdominal migraine episodes 1
If propranolol is contraindicated (asthma, cardiac failure, Raynaud disease, atrioventricular block, depression), use cyproheptadine as alternative 5, 1
For refractory cases not responding to propranolol or cyproheptadine, trial topiramate 50 mg twice daily 4
Continue prophylactic medication for minimum 6 months or until attack cycles cease 1
Provide acute rescue medications (antiemetics, NSAIDs, or sumatriptan) for breakthrough episodes 2, 4, 3

Propranolol remains first-line, with cyproheptadine as preferred alternative due to better tolerability profile in pediatric patients 1, 3
Ibuprofen is the preferred acute analgesic in children 5

Topiramate may be particularly effective in adult abdominal migraine when conventional therapies fail 4
Sumatriptan can be used as abortive therapy in adults with severe attacks 4

Avoid standard prophylactic agents; if treatment is absolutely necessary, propranolol under specialist supervision is the safest option 5
For acute episodes, use acetaminophen and antiemetics only 2

Do not use opioids routinely as they can trigger or worsen abdominal migraine episodes, lead to medication overuse, and cause dependency 2, 6
Avoid oral ergot alkaloids which are poorly effective and potentially toxic 2
Do not discontinue prophylactic therapy prematurely before 6 months, as response may take 2-3 months to manifest 5, 1
Monitor for medication overuse which can perpetuate the condition 2

Before initiating migraine-specific therapy, ensure the diagnosis is correct by confirming:

Recurrent stereotypic episodes of paroxysmal abdominal pain with wellness between episodes 1
Associated symptoms including nausea, vomiting, pallor, anorexia, or photophobia 3
Positive family history of migraine headaches 1, 4
Normal extensive gastrointestinal workup excluding organic pathology 4