An Approach to the Patient With Abdominal Migraine

THE CASE:

A bright, active 10-year-old boy has been experiencing recurrent bouts ofabdominal pain with nausea and occasional vomiting for 3 years. Although hehas had 1 or 2 attacks at school, the pain usually occurs at home-frequentlyon weekends. His mother has been unable to correlate these episodes with particularfoods or activities. She notes that her son has experienced motion sicknessduring long auto trips and during a family holiday in the mountains ofColorado.

In infancy and until the age of 3 years, the child had multiple episodes ofvomiting. When he was about 5 years old, he complained of nausea and dizzinessafter swinging as well as after a trip to an amusement park.

The mother has tried to ascertain whether the pain might be stress-related. Her son has had attacks at times that might be considered stressful, such as beforea soccer game or birthday party; however, he also has them at home. Themother reports that when her son has an episode, he stops what he is doing andlies down in a darkened room. On a few occasions, vomiting has relieved thepain. The mother has migraine headaches and recalls that vomiting relievedthe attacks she had in high school.

To manage the pain, the parents have used over-the-counter remedies, suchas antacids, but the attacks usually resolve in 2 to 4 hours without treatment.

THE DIALOGUE:

Primary care doctor: This case is somewhat ambiguous, and I wanted to consultwith you before proceeding. The patient is usually healthy and busy. He isinvolved in many activities; he enjoys school and sports and complains that thestomach pain interrupts his activities.

The physical examination is normal, and I hesitate to order a battery ofupper GI tests. Although the patient has never complained of headache, I suspecthe may have abdominal migraine. What is your impression?

Headache specialist: I agree with your diagnosis-especially in light of the mother'shistory of migraine headaches. Abdominal migraine, which has been linkedto periodic syndrome and is treated the same way, can occur in children with afamily history of migraine headache.¹ It has also been considered a precursor toadult migraine headache.²

Cyclic vomiting is a principal feature of periodic syndrome. Dr DavidRothner, a pediatric neurologist at the Cleveland Clinic, defines periodic syndromeas "paroxysmal episodes of unexplained pain, nausea, and vomiting. Itsometimes leads to obtundation, dehydration, and recurrent hospitalization.Cyclic abdominal migraine is similar and consists of paroxysmal abdominalpain without vomiting"(personal communication).

Doctor: Does abdominal migraine occur commonly in childrenwho are my patient's age? I have seen similar episodesof abdominal pain in older children, but these children alsocomplained of headache.

Headache specialist: The prevalence of abdominal migrainepeaks at 10 years and declines rapidly.³ However, the disordermay continue into adolescence⁴ and even into adulthood.You may find that migraine headaches similar to theones experienced by his mother eventually develop in yourpatient, either in adolescence or adulthood.

Doctor: Are there any specific criteria to help establish thediagnosis of abdominal migraine? I would like to reassurethe parents that their son does not have a serious disorder.

Headache specialist: The first step is a complete personaland family history.⁵ A physical examination is recommendedas well, and diagnostic criteria have been established(Table).⁴

Always include appendicitis, volvulus, malrotation ofthe bowel, and posterior fossa tumors in the differential diagnosis.In younger children, a metabolic workup can helprule out mitochondrial disorder.

Doctor: What are the key management strategies in abdominalmigraine?

Headache specialist: I would first explain the syndrometo the patient and the parents and reassure them thatthere is no sign of serious illness.⁵ Suggested treatmentmeasures include:

• Avoidance of triggers.
• A low-tyramine or "few-foods" diet.
• Pharmacologic therapy.

Doctor: Which triggers are associated with abdominalmigraine?

Headache specialist: Children can frequently identify theevents that set off the episodes. I find it helpful to havechildren or their parents note these events in a journal.Stress is an important trigger. Because it is impossible toavoid stressful events (such as taking a test or appearingin a recital), I recommend that the child and the parentslearn coping methods. Relaxation training or biofeedbacktraining may be helpful. You might advise parents whoare planning a lengthy automobile trip to make frequentstops and always have water on hand.

Prolonged fasting may precipitate an attack in somechildren and should be avoided. I often recommend ahigh-fiber snack-such as cereal-at bedtime. It may behelpful for these children--as it is for patients with migraineheadaches-to avoid oversleeping on weekends.As with migraineurs, exposure to flickering or glaringlights may precipitate an attack. These environmentaltriggers may be difficult to avoid, but wearing sunglassesor a hat with a visor may help. Finally, exercise may setoff an attack. However, rather than limit the child's activities,I would most likely prescribe medication.

Doctor: What types of dietary measures might be helpful?

Headache specialist: I recommend the same low-tyraminediet for abdominal migraine that I advise for patients withmigraine headache. That is, patients should avoid chocolate,cheese, and caffeine-containing beverages. Other dietarytriggers include food colorings (in some gums andcandies); flavorings (such as those used in snacks likepotato chips); additives such as monosodium glutamate;Asian foods; raisins; and excessive intake of citrus foods.

The few-foods (oligoantigenic) diet is most appropriatelyinitiated in an inpatient pediatric unit, where the patientand the diet can be carefully monitored.⁶ This diet(which can be tried as an adjunct to a low-tyramine regimen)restricts the child at first to a small number of foodsthat are not associated with his or her symptoms. Thesefoods include rice, lamb, and some green vegetables. Thediet is continued for a period during which the child wouldnormally experience 4 attacks-say, 2 weeks. If no attackoccurs, a food trigger is the most likely culprit. New fooditems can be slowly reintroduced. The child and the parentsmust be very patient during this process, because itcan take weeks to months to identify a food trigger. I recommendkeeping a food diary.

Doctor: What are your suggestions regarding drug therapy?

Headache specialist: In most patients, medication is not necessary.When it is indicated, I prescribe agents used to treatchildhood migraine headache. Cyproheptadine,⁷ propranolol,⁸ and divalproex sodium⁵ have all been used prophylactically.The triptans have been used as reversal therapy inolder children with migraine headache; however, data ontriptan use for abdominal migraine are available only foradults.⁹ Controlled trials are needed to assess the benefits ofthese drugs in children.

Inform the parents and the patient that migraine headachesmay develop later. If one of the parents is a migraineur,this will not come as a surprise.

References:

REFERENCES:1. Cullen KJ, MacDonald JT. The periodic syndrome: its nature and prevalence.Med J Aust. 1963;2:167-173.
2. Barlow CF. Headaches and Migraine in Childhood. Oxford, England: SpasticsInternational Medical Publications; 1984.
3. Abu-Arafeh I, Russell G. Prevalence and clinical features of abdominal migrainecompared with those of migraine headache. Arch Dis Child. 1995;72:413-417.
4. Dignan F, Abu-Arafeh I, Russell G. The prognosis of childhood abdominalmigraine. Arch Dis Child. 2001;84:415-418.
5. Russell G, Abu-Arafeh I, Symon DN. Abdominal migraine: evidence for existenceand treatment options. Paediatr Drugs. 2002;4:1-8.
6. Egger J, Carter CM, Wilson J, et al. Is migraine food allergy? A double-blindcontrolled trial of oligoantigenic diet treatment. Lancet. 1983;2:865-869.
7. Lundberg PO. Abdominal migraine-diagnosis and therapy. Headache. 1975;15:122-125.
8. Worawattanakul M, Rhoads JM, Lichtman SN, Ulshen MH. Abdominal migraine:prophylactic treatment and follow-up. J Pediatr Gastroenterol Nutr. 1999;28:37-40.
9. Moran JA. Adult abdominal migraine and sumatriptan: a case report. Ir Med J.1998;91:215-216.
10. Lendvai D, Verdecchia P, Crenca R, et al. Fever: a novelty among the symptomsaccompanying migraine attacks in children. Eur Rev Med Pharmacol Sci.1999;3:229-231.

FOR MORE INFORMATION:

• Lanzi G, Zambrino CA, Balottin U, et al. Periodic syndrome and migraine inchildren and adolescents. Ital J Neurol Sci. 1997;18:283-288.