What is the treatment for abdominal migraines?

Treatment of Abdominal Migraine

For abdominal migraine, use NSAIDs (ibuprofen or naproxen sodium) plus antiemetics (metoclopramide or domperidone) for acute attacks, and initiate propranolol (80-240 mg/day) as prophylactic therapy for patients with recurrent episodes. 1

Acute Attack Management

First-Line Acute Therapy

• Administer NSAIDs immediately at attack onset, specifically ibuprofen or naproxen sodium, as these have proven efficacy for migraine-type pain that characterizes abdominal migraine 1
• Add antiemetics concurrently with metoclopramide 10 mg IV or domperidone to address nausea and vomiting, which are core features of abdominal migraine attacks 1
• The combination of NSAIDs plus antiemetics provides synergistic benefit, addressing both the pain and autonomic symptoms 1

Critical Medications to Avoid

• Never use opioids for abdominal migraine, as they can paradoxically trigger episodes and carry significant risks of dependency and medication overuse headache 1, 2
• Avoid oral ergot alkaloids, which are poorly effective and potentially toxic in this condition 1

Prophylactic Therapy

When to Initiate Prevention

• Start prophylactic medication for patients experiencing recurrent episodes (typically ≥2 attacks per month) 1
• Prevention is essential to reduce attack frequency and restore quality of life 1

First-Line Prophylactic Agent

• Propranolol is the most effective prophylactic medication, with a typical dosing range of 80-240 mg/day for adults 1, 3
• In pediatric studies, propranolol achieved an excellent response (complete cessation of recurrent abdominal pain) in 75% of patients 3
• Start at a low dose and titrate slowly until clinical benefits are achieved or side effects limit further increases 1

Alternative Prophylactic Option

• Cyproheptadine can be used as an alternative prophylactic agent, though it shows lower efficacy than propranolol (33% excellent response vs 75% for propranolol) 3
• Cyproheptadine is associated with weight gain and drowsiness 3

Duration of Prophylactic Treatment

• Continue prophylactic medication for at least 6 months or until symptom cycles have stopped 1, 3
• Some patients require treatment for up to 3 years before achieving sustained remission 1, 3
• Do not abandon prophylactic therapy prematurely, as efficacy requires 2-3 months to assess adequately 1

Treatment Algorithm

1. For acute breakthrough episodes: Use NSAIDs plus antiemetics 1
2. Initiate prophylaxis: Start propranolol at low dose, titrate to 80-240 mg/day 1
3. Reassess after 2-3 months of prophylactic therapy to determine efficacy 1
4. Continue prophylaxis for minimum 6 months after symptom control is achieved 1
5. Consider tapering only after sustained remission, with some patients requiring up to 3 years of treatment 1, 3

Common Pitfalls to Avoid

• Do not use opioids, even for severe pain, as they can trigger abdominal migraine episodes and create dependency 1, 2
• Do not discontinue prophylaxis too early (before 6 months), as this leads to symptom recurrence 1
• Do not start prophylactic doses too high, as this causes poor tolerability and treatment discontinuation 1
• Do not rely solely on acute treatment for patients with frequent attacks (>2 per month), as this increases risk of medication overuse 1