Treatment of Abdominal Migraine
Propranolol is the first-line prophylactic treatment for abdominal migraine, dosed at 80-160 mg orally once or twice daily in long-acting formulations, with a 75% excellent response rate in achieving complete cessation of recurrent abdominal pain. 1, 2
Acute Episode Management
For active attacks, prioritize antiemetics over analgesics to control the cardinal features of nausea and vomiting:
- Metoclopramide or prochlorperazine should be administered via non-oral routes (IV, IM, or rectal) when significant nausea or vomiting is present, as oral medications are poorly tolerated during attacks 1
- Acetaminophen can be added for pain control in acute episodes 1
- In children specifically, ibuprofen is the preferred acute analgesic 1
Prophylactic Treatment Algorithm
First-Line: Propranolol
- Dose at 80-160 mg oral once or twice daily using long-acting formulations 1
- Expect 75% of patients to achieve complete cessation of pain (excellent response), 8% to have fair response (milder, less frequent symptoms), and 17% to have no response 2
- Continue treatment for a minimum of 6 months, as response may take 2-3 months to manifest 1
Second-Line: Amitriptyline
- Use 10-100 mg orally at bedtime when propranolol fails or is contraindicated 1
Alternative: Cyproheptadine
- Consider when propranolol is contraindicated 1
- Expect 33% excellent response and 50% fair response, making it less effective than propranolol but still beneficial 2
- Typical treatment duration ranges from 10 months to 3 years 2
Emerging Option: Topiramate
- Consider topiramate 50 mg twice daily for refractory adult cases, particularly in patients with extensive negative gastrointestinal workups 3
Special Population Considerations
Pregnant Patients
- Acetaminophen and antiemetics are safe for acute episodes 1
- Propranolol under specialist supervision is the safest prophylactic option when prevention is necessary 1
Pediatric Patients
- Ibuprofen is preferred over acetaminophen for acute pain 1
- Peak incidence occurs at age 7 years, with diagnosis typically between ages 3-10 years 4
Critical Pitfalls to Avoid
Never use opioids routinely, as they can trigger or worsen abdominal migraine episodes, lead to medication overuse, and cause dependency—this is particularly important in the perioperative setting 1, 5
- Avoid oral ergot alkaloids, which are poorly effective and potentially toxic 1
- Do not discontinue prophylactic therapy before 6 months, even if initial response seems poor, as therapeutic effect may take 2-3 months to manifest 1
- Monitor for medication overuse, which can perpetuate the condition 1
- Nearly half of patients (46%) prematurely discontinue propranolol before 6 months, which may lead to treatment failure 2