What are the recommended evaluations and treatments for a 15-year-old patient with stomach pain and headaches?

Evaluation and Management of a 15-Year-Old with Stomach Pain and Headaches

Screen immediately for somatic symptom disorder, as recurrent abdominal pain and headaches together account for a substantial proportion of pediatric visits and frequently represent functional disorders rather than organic pathology, with 10% of adolescents reporting frequent symptoms and up to 24% of children with recurrent abdominal pain meeting criteria for abdominal migraine. 1, 2

Initial Diagnostic Approach

Red Flags Requiring Urgent Evaluation

• Bilious vomiting (indicates life-threatening or surgical disorder in younger patients) 3
• Headache that worsens with Valsalva maneuver or awakens from sleep (requires neuroimaging) 1
• Progressive worsening of either symptom (warrants imaging) 1
• Fever with neck stiffness (suggests meningitis) 4
• Unexplained neurologic findings on examination (requires neuroimaging) 1

Key Historical Features to Elicit

• Pattern and timing: Are symptoms episodic or continuous? Do they occur together or separately? 1
• Abdominal pain characteristics: Midline location, duration of 1-72 hours, associated with pallor, nausea, vomiting, anorexia, or photophobia suggests abdominal migraine 5, 2
• Headache characteristics: Throbbing quality, unilateral location, duration, associated nausea/vomiting, photophobia/phonophobia suggests migraine 1
• Stressors and psychological factors: Recent stressful events, anxiety symptoms, school avoidance, family dynamics 1, 6
• Symptom fluctuation: Symptoms that fluctuate with activity or stress suggest functional disorder 1
• Return to baseline: Complete resolution between episodes strongly suggests abdominal migraine 5, 2

Physical Examination Priorities

• Neurologic examination: Must be normal to avoid neuroimaging for headache 1
• Abdominal examination: Look for succussion splash, masses, organomegaly, or peritoneal signs 1
• General appearance: Pallor during episodes, signs of chronic illness, growth parameters 1

Diagnostic Workup Strategy

When Laboratory/Imaging is NOT Indicated

• Normal physical examination with typical functional pain pattern 3
• Headache meeting strict migraine criteria with normal neurologic exam 1
• Symptoms consistent with abdominal migraine (episodic, midline pain with vasomotor symptoms, return to baseline) 5, 2

When to Consider Testing

• Persistent symptoms despite reassurance and initial management 3
• Atypical features not meeting functional disorder criteria 1
• Constitutional symptoms (weight loss, fever, growth failure) 3

Psychological Screening (ESSENTIAL)

Implement systematic screening for anxiety, functional disability, and pain levels using validated tools (Screen for Child Anxiety and Related Disorders, Functional Disability Inventory), as 43% of children with abdominal pain have clinically significant anxiety, which correlates with higher pain and disability. 6

Most Likely Diagnosis: Abdominal Migraine with Comorbid Headache

Abdominal migraine affects 0.2-4.1% of children but is vastly underdiagnosed, with studies showing only 4-15% of children with chronic recurrent abdominal pain receiving this diagnosis despite meeting criteria. 5, 2

Diagnostic Criteria (Rome IV/ICHD-2)

• Paroxysmal episodes of acute, midline abdominal pain lasting 1-72 hours 5, 2
• Associated with at least 2 of: anorexia, nausea, vomiting, pallor, headache, photophobia 5
• Complete return to baseline health between episodes 5, 2
• Not attributed to another medical condition 2

Treatment Algorithm

Acute Episode Management

For abdominal pain during acute episodes:

• First-line: NSAIDs (ibuprofen 10 mg/kg/dose, maximum 800 mg) at symptom onset 1, 4
• Antiemetics: Metoclopramide 10 mg or prochlorperazine (dose-adjusted for age/weight) for nausea 1, 4
• Avoid opioids and butalbital compounds (risk of dependency and medication-overuse headache) 1, 4

For headache during acute episodes:

• Mild-to-moderate: Naproxen sodium 500 mg or ibuprofen 400-800 mg at onset 4
• Moderate-to-severe: Consider triptan therapy (sumatriptan 50-100 mg oral, or nasal spray 5-20 mg) if age-appropriate and no contraindications 4
• Combination therapy: Aspirin 500 mg + acetaminophen 500 mg + caffeine 130 mg for enhanced efficacy 4
• Limit acute medications to maximum twice weekly to prevent medication-overuse headache 4

Preventive Therapy (Indicated if >2 Episodes Per Month)

Initiate preventive therapy when attacks occur more than twice monthly or produce disability lasting 3+ days, as this reduces attack frequency and restores quality of life. 4

First-line preventive options:

• Propranolol 80-240 mg/day (divided doses) 4
• Amitriptyline 10-30 mg at bedtime (particularly useful for mixed headache/abdominal pain) 4
• Cyproheptadine (antihistamine with antimigraine properties, well-tolerated in adolescents) 5

Non-Pharmacologic Interventions (CRITICAL COMPONENT)

Implement cognitive behavioral therapy, relaxation techniques, and biofeedback as first-line interventions, as these address the central pain amplification mechanisms and psychological factors that maintain chronic pain. 1, 4

• Breathing techniques and progressive muscle relaxation 1
• Cognitive behavioral therapy for patients with insight into thought-pain relationships 1
• Hypnotherapy for visceral hypersensitivity (requires certified provider) 1
• Address anxiety and depression with mental health professional involvement 1, 6

Critical Pitfalls to Avoid

1. Do not dismiss symptoms as "just psychological" - explain the physiological basis (visceral hypersensitivity, central sensitization) while acknowledging psychological modulation 1

2. Do not order extensive testing without clear indication - only 1 in 15 school-age children with abdominal pain has serious pathology like appendicitis 3

3. Do not allow escalating acute medication use - this creates medication-overuse headache; transition to preventive therapy instead 4

4. Do not overlook family dynamics - parental anxiety and coping styles significantly modulate symptom expression 7

5. Do not delay psychological referral - 21% of youth have clinical elevations in anxiety, pain, and disability requiring integrated care 6

Follow-Up Strategy

• Reassess in 2-4 weeks after initiating treatment 1
• Monitor medication frequency to ensure <2 days/week acute medication use 4
• Track symptom diary documenting triggers, duration, associated symptoms 1
• Evaluate preventive therapy efficacy after 2-3 months (oral agents) 4
• Coordinate with mental health provider for integrated biopsychosocial approach 1, 6