Abdominal Migraine: The Essentials

Abdominal migraine is a type of migraine most often seen in children, ages five- to nine-years-old. It can occur in adults as well. Abdominal Migraine consists primarily of abdominal pain, nausea, and vomiting.  Small children will complain of “tummy aches”, refuse food or drink, and usually vomit before the attack is over. Other associated symptoms such as hypersensitivity to sensory stimuli, nausea, and vomiting are common. It was recognized as a form of Migraine disease as links were made to other family members having Migraines. It was also observed that children who had this disorder grew into adults with Migraine with and without aura.

Diagnosis

• The attacks last at least 2 hours and can be as long as 72 hours.
• As with any form of Migraine, there is no diagnostic test to confirm Abdominal Migraine.
• Diagnosis is achieved by
  • reviewing both family and patient medical history
  • evaluating the symptoms
  • performing an examination to rule out other causes of the symptoms.
• Other conditions that should be ruled out to arrive at a diagnosis of abdominal Migraine include:
  • urogenital disorders
  • peptic ulcer
  • cholecystitis (gall bladder)
  • duodenal obstruction
  • gastroesophageal reflux
  • Crohn’s disease
  • irritable bowel syndrome.
• If there is any alteration in consciousness, seizure disorders should also be ruled out.
• This is especially true if one more family member has already been diagnosed with migraine.
• A diagnosis is confirmed when 5 or more attacks occur, absent headache, with 2 or more associated symptoms:
  • anorexia
  • nausea
  • vomiting
  • pallor 
• If a headache is present, then the more accurate diagnosis is Migraine without Aura.

Symptoms

• Severe, dull pain in the middle of the abdomen
• Nausea and vomiting
• Lack of appetite (anorexia)
• Pallor (pale skin that feels cold and clammy)
• Dark shadows under the eyes
• Flushing of the skin

Kids often complain of vague belly pain, so it is important to note that the symptoms of Abdominal Migraine are severe enough to interfere with even play time. A child who is experiencing an Abdominal Migraine attack will be very sick, unwilling or unable to eat, may cry or whine, and frequently vomits. Most of the time Abdominal Migraine is a predictive of developing Migraine later in life.

Treatment

The treatment for Abdominal Migraine is very similar to the treatment of other Migraine disorders and depends greatly on the age of the child. Anti-nausea medications are used in addition to NSAIDs or triptans. The choice of medications is somewhat affected by the age of the patient. When abdominal Migraines are frequent, the same preventive therapies used for other Migraines can be explored.

ICHD-3 Diagnostic Criteria:

Description:

An idiopathic disorder seen mainly in children as recurrent attacks of moderate to severe midline abdominal pain, associated with vasomotor symptoms, nausea and vomiting, lasting 2-72 hours and with normality between episodes. Headache does not occur during these episodes.

Diagnostic criteria:

1. At least five attacks of abdominal pain, fulfilling criteria B–D
2. Pain has at least two of the following three characteristics:
   1. midline location, periumbilical or poorly localized
   2. dull or “just sore” quality
   3. moderate or severe intensity
3. At least two of the following four associated symptoms or signs:
   1. anorexia
   2. nausea
   3. vomiting
   4. pallor
4. Attacks last 2-72 hours when untreated or unsuccessfully treated
5. Complete freedom from symptoms between attacks
6. Not attributed to another disorder.

Note:

In particular, history and physical examination do not show signs of gastrointestinal or renal disease, or such disease has been ruled out by appropriate investigations.

Comment:

1. Pain of 1.6.1.2 Abdominal migraine is severe enough to interfere with normal daily activities.
2. In young children the presence of headache is often overlooked. A careful history of presence or absence of headache must be taken and, when headache or head pain during attacks is identified, a diagnosis of 1.1 Migraine without aura should be considered.
3. Children may find it difficult to distinguish anorexia from nausea. Pallor is often accompanied by dark shadows under the eyes. In a few patients, flushing is the predominant vasomotor phenomenon.
4. Most children with abdominal migraine will develop migraine headache later in life.

Sources:

1. Evans, Randolph W., MD; Mathew, Ninan T., MD, FRCP(C). “Handbook of Headache.” Lippincott Williams & Wilkins, 2005, second edition.
2. International Headache Society (IHS) (2018). 1.6.1.2 Abdominal Migraine (n.d.). Retrieved April 23, 2018, from https://www.ichd-3.org/1-migraine/1-6-episodic-syndromes-that-may-be-associated-with-migraine/1-6-1-recurrent-gastrointestinal-disturbance/1-6-1-2-abdominal-migraine/
3. South, Valerie, RN. “Migraine: Everything you need to know.” Key Porter Books, 1996.