Abdominal Migraine in Pediatric Patients

Abdominal migraine is a functional gastrointestinal (GI) disorder affecting an estimated 0.2% to 4.1% of children, with a preponderance of cases in girls.¹ While this condition has also been noted in adults, most reported cases have been observed in pediatric patients.² The age range in which abdominal migraine typically occurs is 3 to 10 years, with reported peaks at ages 5 and 10 years.¹

As outlined in the Rome IV criteria, abdominal migraine is “defined as a functional abdominal pain syndrome with features of migraine such as paroxysmal abdominal pain lasting at least 1 hour or more, occurring at least twice in 6-month period, with at least 2 associated symptoms such as anorexia, nausea, emesis, photophobia, headache, and pallor,” explained Jessica Barry, MD, a physician in the department of gastroenterology, hepatology, and nutrition at Cleveland Clinic in Ohio. “The episodes of chronic recurrent abdominal pain can range in severity as well as abdominal location (periumbilical to generalized), with events separated by weeks to months.”

Symptoms follow a stereotypical pattern, interfere with normal activities, and cannot be explained by another medical condition.³ Children with abdominal migraine are otherwise healthy and return to their baseline health between pain episodes.¹ 

Association with Migraine Headache

Many children with abdominal migraine have shown a personal or family history of migraine headaches.⁴ In a study of 150 children with abdominal migraine, 90% of cases were associated with a family history of migraine headache in a first-degree relative, and a retrospective study of children with abdominal migraine or cyclic vomiting syndrome (CVS) found a personal or family history of migraine headache in 70% and 65% of patients, respectively.¹

These findings, along with some of the shared symptoms and patterns between abdominal migraine and migraine headache, point to a similar pathogenesis that may be “explained by the bidirectional communication between neurons in the brain and gut,” according to a 2020 review by Azmy and Qualia.¹

A study comparing children with abdominal migraine to those with migraine headache (of which 24% had both disorders) found similar presentations and associated symptoms, shared precipitating factors such as stress, travel, and fatigue, as well as common relieving factors including eating and resting.¹

However, the mechanistic pathways and precipitating factors of abdominal migraine remain unclear. “Its classification as a functional GI disorder supports the fact that the exact mechanism and pathophysiology of the disorder are difficult to pinpoint,” Dr Barry stated. Similar to other functional abdominal pain syndromes, the pathophysiology is believed to involve a combination of visceral hypersensitivity, alterations in the gut-brain enteric nervous system, and psychological factors such as depression, anxiety, and high stress levels.¹

Diagnostic Considerations

Diagnosis of abdominal migraine may be challenging due to overlapping symptoms with other functional and organic etiologies of abdominal pain; a child with abdominal migraine may also have an additional functional abdominal pain disorder.¹

“There are no confirmatory diagnostic tests for abdominal migraine, and the initial differential of abdominal pain in children is broad and requires evaluation based on history and physical exam findings,” Dr Barry said. “Abdominal migraine is a clinical diagnosis, and the cyclical nature of the disease poses a diagnostic challenge, as the diagnosis requires recognition of the pattern of events and documented symptoms.”

The stereotypical pattern of recurring pain episodes over time represents a key defining feature of abdominal migraine, as compared with functional abdominal pain not otherwise specified, for example, which tends to involve less incapacitating pain than abdominal migraine.¹

CVS is also associated with migraine headache, often involves abdominal pain, and can co-occur in children with abdominal migraine. The key difference is that “in abdominal migraine, pain predominates over vomiting, while nausea and vomiting predominate over abdominal pain in CVS,” Raucci et al wrote in a 2020 review.⁵ Findings have also shown that “certain pain characteristics are more likely in CVS such as burning, non-midline, mild and not interfering in daily activities, and duration of >1 h.”⁵

Dr Barry also noted that in abdominal migraine, the child’s weight, linear velocity, and baseline screening lab values should remain normal.

Treatment Options

There is scant evidence regarding treatment strategies for abdominal migraine. The range of pharmacologic and nonpharmacologic treatment approaches have been primarily derived from anecdotal evidence and approaches used in the treatment of migraine headache.¹

Azmy and Qualia encourage providers to discuss the STRESS mnemonic with patients and family members to aid in the management of abdominal migraine: (S)tress management to possibly include cognitive behavioral therapy, (T)ravel tips to avoid motion sickness and other potentially triggering factors, (R)est and adequate sleep hygiene, (E)mergency symptoms for parents to report if they arise, such as weight loss, changes in growth pattern, fever, bilious vomiting, chronic diarrhea, and dysphagia, (S)parkling and flashing lights and other visual disturbances to be avoided, and (S)nacking and general eating habits to avoid, including prolonged fasting and consumption of high-amine foods.¹

Preventive pharmacologic therapies supported by the limited available data include pizotifen syrup (0.25 mg twice daily), propranolol (10-20 mg 2 or 3 times daily), cyproheptadine syrup (0.25-0.50 mg/kg daily), and flunarizine (5.0-7.5 mg/day).¹

“The focus is on decreasing the total number of episodes via use of prophylactic medications, with the goal of improving long-term outcomes and quality of life for affected patients,” Dr Barry stated.

Abortive therapies for acute attacks may include ibuprofen (10 mg/kg), acetaminophen (15 mg/kg), and intranasal sumatriptan (10 mg).¹

Prognosis and Ongoing Needs

Research findings suggest that most cases of abdominal migraine resolve by adulthood, although many patients subsequently develop classic migraine.² In an earlier study, abdominal migraine eventually resolved in 61% of cases, and 70% of these patients developed migraine headache in adulthood.¹ Accordingly, abdominal migraine is considered a pediatric precursor of migraine headache.²

Substantial work is needed to clarify the pathophysiology and trajectory of abdominal migraine. Additionally, certain therapies used in migraine headache treatment warrant investigation in abdominal migraine patients, including noninvasive vagal nerve stimulation and calcitonin gene-related peptide monoclonal antagonists.¹

There is also an ongoing need for clinician education regarding this debilitating condition. “Abdominal migraine affects up to 4% of children, thus education pertaining to diagnosis and management of abdominal migraines remains an important need,” Dr Barry emphasized. ¹ “Spreading awareness among medical providers may increase referral to gastroenterology and migraine specialists to aid in earlier therapy interventions and improve patient outcomes.”

References

1. Azmy DJ, Qualia CM. Review of abdominal migraine in children. Gastroenterol Hepatol (N Y). 2020;16(12):632-639.
2. LenglarT L, Caula C, Moulding T, Lyles A, Wohrer D, Titomanlio L. Brain to belly: abdominal variants of migraine and functional abdominal pain disorders associated with migraine. J Neurogastroenterol Motil. 2021;27(4):482-494. doi:10.5056/jnm20290
3. Rome Foundation. Rome IV Criteria. January 16, 2016. Accessed February 22, 2022. https://theromefoundation.org/rome-iv/rome-iv-criteria/
4. Mani J, Madani S. Pediatric abdominal migraine: current perspectives on a lesser known entity. Pediatric Health Med Ther. 2018;9:47-58. doi:10.2147/PHMT.S127210
5. Raucci U, Borrelli O, Di Nardo G, et al. Cyclic vomiting syndrome in children. Front Neurol. Published online November 2, 2020. doi:10.3389/fneur.2020.583425