What are the signs and management of abdominal migraines?

Signs and Management of Abdominal Migraine

Abdominal migraine presents as recurrent, stereotypic episodes of paroxysmal midline or periumbilical abdominal pain lasting hours to days, accompanied by nausea, vomiting, anorexia, pallor, and often headache or photophobia, with complete wellness between episodes. 1, 2, 3

Clinical Presentation and Diagnostic Features

The cardinal signs to recognize include:

• Paroxysmal abdominal pain that is moderate to severe, typically midline, periumbilical, or diffuse in location 3, 4
• Associated symptoms during attacks: nausea, vomiting, anorexia, pallor, headache, and photophobia 3, 5
• Stereotypic pattern: episodes are remarkably similar from attack to attack 2, 5
• Complete wellness between episodes: patients return to baseline health with no symptoms between attacks 2, 3
• Duration: attacks typically last hours to a few days 5
• Strong family history of migraine: this significantly strengthens the diagnosis 1, 2
• Peak age: most common at 3-10 years with peak incidence at age 7, though can occur in adults 4

Important Diagnostic Pitfall

Do not dismiss abdominal pain as excluding other diagnoses—most patients with cyclic vomiting syndrome also have abdominal pain during episodes, making differentiation challenging. 6 The key distinguishing feature is the stereotypic, recurrent pattern with complete wellness between episodes.

Acute Management of Episodes

First-Line Acute Treatment

For breakthrough episodes, use NSAIDs with antiemetics as needed. 1 Specific options include:

• Ondansetron 8 mg sublingual/oral every 4-6 hours 6
• Promethazine 12.5-25 mg oral/rectal every 4-6 hours 6
• Prochlorperazine 5-10 mg every 6-8 hours or 25 mg suppository every 12 hours 6

Abortive Therapy

Sumatriptan plus antiemetics during the prodromal phase can abort attacks if patients recognize early warning symptoms. 6 Patient education on recognizing prodromal symptoms (occurring in ~65% of patients, lasting median 1 hour before onset) is critical for successful intervention. 6

Prophylactic Treatment

When to Initiate Prevention

Consider prophylactic treatment when patients are adversely affected on ≥2 days per month despite optimized acute treatment. 1

First-Line Prophylaxis

Propranolol is the most effective first-line prophylactic agent, with 75% of patients achieving complete cessation of symptoms. 2 This represents the strongest evidence from the pediatric literature, though the principle applies to adults as well. 1, 2

Second-Line Prophylaxis Options

When propranolol is contraindicated or ineffective:

• Beta-blockers (propranolol, metoprolol) remain effective second-line options 1
• Amitriptyline, particularly when comorbid sleep disturbances exist 1
• Candesartan has evidence for migraine prophylaxis 1
• Cyproheptadine showed 33% excellent response and 50% fair response in pediatric studies 2
• Topiramate 50 mg twice daily has case report evidence in adults 7

Duration of Prophylactic Treatment

Continue prophylactic medication for 6 months or until cycles have stopped, then consider discontinuing after 3-6 months of stability to determine if prophylaxis is still needed. 1, 2 In practice, 46% of patients on propranolol took medication less than 6 months, while others required 6 months to 3 years. 2

Non-Pharmacological Management

Essential Lifestyle Modifications

• Maintain a headache/abdominal pain diary to identify triggers and monitor treatment effectiveness 1
• Regular meals, consistent sleep patterns, stress management, and adequate hydration 1
• Regular exercise (40 minutes three times weekly) has been shown as effective as relaxation therapy or topiramate for migraine prevention 1

Behavioral Interventions

Cognitive behavioral therapy (CBT), relaxation training, or biofeedback have demonstrated efficacy for migraine management. 1 These should be initial interventions before escalating to pharmacotherapy, particularly in children. 4

Monitoring and Follow-Up

• Schedule regular follow-up visits to monitor frequency, severity, and response to treatment 1
• Use standardized assessment tools like the Headache Impact Test (HIT-6) to objectively monitor progress 1
• Adjust treatment based on response and tolerability 1

Critical Pitfall: Medication Overuse

Medication overuse headache can occur with frequent use of acute medications (≥15 days/month for NSAIDs or ≥10 days/month for other acute medications). 1 This is a common trap that worsens the underlying condition.

Special Population Considerations

Pregnant Women

Paracetamol (acetaminophen) is the safest option for acute treatment; avoid preventive medications if possible. 1

Older Adults

Carefully monitor for adverse effects, particularly with triptans if cardiovascular risk factors are present. 1

Children

Bed rest alone can be sufficient for mild episodes; use ibuprofen for acute treatment and propranolol, amitriptyline, or topiramate for prevention. 8

Prognosis

Most patients with abdominal migraine have complete resolution of symptoms, but they have a strong propensity to develop typical migraine headaches later in life. 4 This natural history underscores the importance of recognizing abdominal migraine as a migraine variant rather than a purely gastrointestinal disorder.