Pediatric abdominal migraine: current perspectives on a lesser known entity

Figures & data

Table 1 Abdominal migraine – differential diagnosis

Gastrointestinal disorders

Acid peptic disease (esophagitis, gastritis, peptic ulcer disease)

Eosinophilic diseases (esophagitis, gastritis, enteropathy)

Celiac disease

Gall bladder disease (choledochal cyst, cholelithiasis, cholecystitis)

Gastroesophageal reflex

Small bowel obstruction

Inflammatory bowel disease

Pancreatitis

Other functional abdominal pain disorders (functional dyspepsia, irritable bowel syndrome, cyclic vomiting syndrome, functional abdominal pain – not otherwise specified)

Lactose intolerance

Chronic hepatitis

Surgical causes (hernia, appendicitis, intussusception)

Central nervous system disorders

Posterior fossa disorders

Epilepsy

Intracranial hypertension

Metabolic

Acute intermittent porphyria

Lead poisoning

Diabetes mellitus

Urogenital causes

Urinary tract infection

Ureteropelvic junction obstruction

Nephrolithiasis

Hematologic/oncologic

Sickle cell disease

Tumors (intestinal polyps)

Infectious

Parasitic

Helicobacter pylori gastritis

Pneumonia

Rheumatic

Collagen vascular disease

Others

Foreign body

Munchausen syndrome by proxy

Trauma

Table 2 Alarm symptoms and signs in children with abdominal migraine

Alarm symptoms

Persistent right upper or right lower quadrant pain

Pain radiating to back

Persistent or bilious vomiting

Gastrointestinal blood loss

Hematuria

Chronic and unexplained diarrhea

Involuntary weight loss

Recurrent or unexplained fever

Dysphagia

Hematochezia, melena

Occult gastrointestinal blood loss

Nocturnal symptoms

Unexplained fever

Family history of inflammatory bowel disease, celiac disease, or familial

Mediterranean fever

Dysuria

Delayed puberty

Joint pain or joint swelling

Alarm signs

Deceleration of linear growth

Signs of peritonitis (rebound, guarding)

Leucocytosis

Hypoalbuminemia

Localized abdominal tenderness, away from umbilicus

Elevated inflammatory markers

Uveitis

Oral lesions

Icterus

Pallor

Rash with no identifiable cause

Organomegaly including hepatomegaly or splenomegaly

Arthritis

Costovertebral angle tenderness

Tenderness over the spine

Perianal abnormalities – anal skin tags, fissures

Table 3 Abdominal migraine: triggers

Bright or flickering light

Poor sleep

Travel

Prolonged fasting

School or family stressors

Dietary triggers (citrus food, caffeine, cheese, chocolate, carbonated drinks, colorings and flavorings)

Table 4 Diagnostic studies that should be considered in children presenting with chronic and recurrent abdominal pain

Blood studies

Full blood count

Erythrocyte sedimentation rate

C-reactive protein

Electrolytes

Urea and creatinine

Glucose

Liver function tests

Amylase and lipase

Celiac antibodies

Pregnancy test

Urine and stool studies

Urinalysis with microscopy, culture, and sensitivity

Stool occult blood and microscopy

Stool test for Helicobacter pylori antigen

Fecal calprotectin

Radiological studies

Abdominal X-ray

Ultrasound of the abdomen and pelvis

Contrast study of upper gastrointestinal tract and small bowel

Magnetic resonance imaging of brain

Endoscopic procedures

Esophagogastroduodenoscopy

Colonoscopy

Figure 1 Diagnostic algorithm for abdominal migraine.

Table 5 Treatment of abdominal migraine

Nonpharmacologic therapy

Explanation and reassurance

Avoidance of triggers

Modified diet

Psychotherapy

Pharmacotherapy

Abortive therapy

Intranasal sumatriptan

IV valproate

Prophylactic therapies

Beta blocker: propranolol

5-HT antagonists: cyproheptadine

Calcium channel blockers: flunarizine

5-HT agonist with antihistamine properties: pizotifen

Abbreviations: IV, intravenous; HT, hydroxytryptamine.

Table 6 Abortive and prophylactic therapy in abdominal migraine

Study	Mechanism of action	Type of study	Participants	Interventions	Results
Abortive therapy with sumatriptan (Kakisaka et al)^Citation66	Serotonin/5-hydroxytryptophan agonist (5-HT ID)	Case report (2010)	1 child with abdominal migraine	Intranasal sumatriptan for acute attack of abdominal pain	Complete resolution of pain
Abortive therapy with IV valproate (Tan et al)^Citation40	GABA agonist	Case report (2006)	2 children with abdominal migraine	IV valproate	Symptomatic relief
Prophylactic therapy with cyproheptadine (Madani et al)^Citation70	First-generation antihistamine with anti-serotoninergic and calcium channel blocking properties	Retrospective study (2016)	18 children with abdominal migraine	0.13–0.2 mg/kg/day	72% of patients with improvement in symptoms
Prophylactic therapy with flunarizine (Kothare)^Citation68	Calcium channel blocker	Clinical trial (2005)	8 children with abdominal migraine	7.5 mg daily PO	61% reduction in frequency and 51% reduction in duration
Prophylactic therapy with propranolol vs cyproheptadine (Worawattanakul et al)^Citation62	Propranolol – beta blocker Cyproheptadine – first-generation antihistamine with anti-serotoninergic and calcium channel blocking properties	Retrospective study (1999)	36 children with abdominal migraine (12 treated with cyproheptadine; 24 treated with propranolol)	Cyproheptadine 0.25–0.5 mg/kg/day of propranolol 10–20 mg BID–TID	33% complete resolution, 50% fair response, 17% no response 75% excellent response, 8% fair response, 17% no response
Prophylactic therapy with pizotifen syrup (Symon and Russell)^Citation69	Serotonin antagonist (5-HT 2A and 2D)	Double-blind placebo controlled trial (1995)	14 children with abdominal migraine	5 mL BID to TID (0.25 mg/5 mL)	Effective in 70% of patients

Abbreviations: HT, hydroxytryptamine; BID, twice a day; TID, thrice a day; PO, orally; GABA, gamma aminobutyric acid; IV, intravenous.

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