What is the recommended treatment for abdominal migraines in adolescents?

Treatment for Abdominal Migraines in Adolescents

Start with ibuprofen (7.5-10 mg/kg) as first-line acute treatment for abdominal migraine episodes in adolescents, and consider preventive therapy with amitriptyline combined with cognitive behavioral therapy or topiramate if episodes are frequent or disabling. 1, 2

Acute Treatment Approach

• Ibuprofen at 7.5-10 mg/kg is the first-line acute therapy for abdominal migraine attacks, with acetaminophen (15 mg/kg) as an alternative if NSAIDs are not tolerated 1, 2

• Early treatment when symptoms begin is crucial for optimal response—waiting until symptoms are severe reduces medication efficacy 1

• For adolescents with inadequate response to NSAIDs, triptans such as sumatriptan nasal spray (5-20 mg), rizatriptan ODT, or almotriptan oral may be considered as second-line options 1, 2, 3

• If significant nausea or vomiting accompanies the abdominal pain, consider non-oral formulations or add an antiemetic 1

• For refractory cases requiring hospitalization, intravenous dihydroergotamine (DHE) starting at 0.5 mg has shown effectiveness in case series, though this should only be used when standard preventive medications (amitriptyline, topiramate, verapamil) have failed 4

Preventive Treatment Strategy

• Consider preventive therapy if abdominal migraine episodes are frequent, disabling, or significantly impact quality of life 1

• First-line preventive options include:

  • Amitriptyline combined with cognitive behavioral therapy 1
  • Topiramate 1
  • Propranolol 1

• Flunarizine (5 mg/day) is likely effective based on available data, though evidence is limited 2, 5

• Medications with insufficient evidence or not recommended include divalproex sodium (also contraindicated in females of childbearing potential due to teratogenicity), onabotulinumtoxinA, amitriptyline alone without behavioral therapy, and nimodipine 1, 2

Non-Pharmacologic Interventions

• Lifestyle modifications are essential and should be implemented alongside any pharmacologic treatment: 1, 2

  • Maintain regular sleep schedules
  • Keep consistent meal times
  • Ensure adequate hydration
  • Implement stress management techniques

• Behavioral interventions such as relaxation techniques, biofeedback, and cognitive behavioral therapy may be more effective than pharmacotherapy alone for migraine prophylaxis in children and adolescents 1, 2

• Identify and avoid specific triggers when evident 1

Critical Clinical Considerations

• Monitor for medication overuse—acute medications should not be used more than 10 days per month to prevent medication overuse headache 1

• Approximately two-thirds of pediatric migraine patients improve with standard therapy, but one-third require more aggressive approaches 1

• Use headache/symptom calendars to monitor frequency, intensity, and medication use to guide treatment adjustments 1

• An individualized approach considering developmental factors and potential psychiatric comorbidities is necessary, as there is a high rate of psychiatric comorbidity in pediatric migraine patients 1, 2

• Abdominal migraine in childhood may evolve into classic migraine headaches in adulthood, making early effective treatment important 6

Treatment Algorithm

1. Acute episode: Start ibuprofen 7.5-10 mg/kg at symptom onset 1, 2
2. If inadequate response: Add or switch to a triptan (sumatriptan nasal spray, rizatriptan ODT, or almotriptan) 1, 3
3. If episodes are frequent (≥4 per month) or disabling: Initiate preventive therapy with amitriptyline plus cognitive behavioral therapy, topiramate, or propranolol 1
4. If refractory to standard preventives: Consider hospitalization for IV DHE therapy 4
5. Throughout treatment: Implement lifestyle modifications and behavioral interventions 1, 2