Diagnostic Criteria for Abdominal Migraine
Abdominal migraine is diagnosed when a patient has recurrent episodes of severe, midline abdominal pain lasting hours, accompanied by anorexia, nausea, vomiting, and pallor, with complete wellness between episodes and no other identifiable cause. 1
Core Diagnostic Features
The syndrome requires the following key elements for diagnosis:
- Recurrent stereotypic episodes of paroxysmal abdominal pain with nausea and/or vomiting, with complete wellness between episodes 2
- Midline abdominal pain of sufficient severity to interfere with normal activities, lasting for prolonged periods (typically hours) 1
- Associated symptoms including pallor, headache, anorexia, nausea, and vomiting 1
- Normal gastrointestinal workup with no other apparent underlying disease to explain the symptoms 2, 3
Supporting Diagnostic Elements
Several features strengthen the diagnosis but are not absolute requirements:
- Positive family history of migraine, particularly in first-degree relatives (present in over 50% of cases) 1
- Age of onset typically in childhood, though adult cases are increasingly recognized 3, 4
- Response to anti-migraine therapy can be diagnostic and therapeutic, with marked symptom relief confirming the diagnosis 1
Clinical Presentation Patterns
The pain characteristics are distinctive:
- Poorly localized, dull, and severe abdominal pain rather than sharp or cramping 4
- Episodic nature with complete resolution between attacks, distinguishing it from chronic functional abdominal pain 2
- Refractory to conventional analgesics and antiemetics during acute episodes 3
Differential Diagnosis Considerations
A critical pitfall is failing to exclude organic causes before diagnosing abdominal migraine:
- Extensive gastrointestinal evaluation must show normal results, including imaging and laboratory tests 3, 4
- The diagnosis should only be considered after conventional therapies for functional dyspepsia or other gastrointestinal disorders have failed 4
- In adults particularly, the diagnosis requires a high index of suspicion as it is more commonly recognized in children 3
Treatment Options
Prophylactic Therapy (First-Line)
Propranolol is the most effective prophylactic treatment, with 75% of patients achieving complete cessation of symptoms and only 17% showing no response 2. This represents the strongest evidence for any single agent.
Alternative prophylactic options include:
- Cyproheptadine as second-line, though less effective (only 33% excellent response vs 75% for propranolol) 2
- Topiramate 50 mg twice daily has shown efficacy in adult cases and is recommended when beta-blockers are contraindicated 3
- Calcium channel blockers (such as lomerizine) have demonstrated effectiveness in case reports 4
Duration of Prophylactic Treatment
- Minimum 6 months or until symptom cycles have stopped is recommended 2
- However, nearly half of patients (46%) in the propranolol group discontinued medication before 6 months once symptoms resolved 2
- Some patients require treatment for up to 3 years 2
Abortive Therapy
- Sumatriptan has shown effectiveness in some patients for acute symptom relief 3
- Loxoprofen (an NSAID) combined with lomerizine provided relief in documented cases 4
- Opioid-sparing approaches are strongly recommended, as opioids can trigger abdominal migraine episodes 5
Key Clinical Pitfalls
The most common error is misdiagnosing functional dyspepsia or other gastrointestinal disorders when abdominal migraine is the actual cause. This leads to prolonged suffering with ineffective treatments 4. The diagnosis requires actively considering abdominal migraine in the differential, particularly when: