| What is an abdominal migraine? |
In the broad sense it is a functional disorder (without structural or biochemical diagnostic abnormalities).
It is an episodic syndrome in the migraine spectrum and consists of central abdominal pain, intermittent and severe enough to interrupt daily activities. The pain is accompanied by migraine characteristics such as sensory alterations (photo and phonophobia), anorexia, nausea, vomiting and paleness.
The patient is symptom-free between episodes with a normal physical examination, stable body mass index, and consistent neurological development. These elements constitute the consensus diagnostic criteria for abdominal migraine (the International Classification of Headache Associated Disorders and the Rome IV Classification of Gastrointestinal Disorders) and previous descriptions.
There is debate regarding the diagnostic criteria; headache is omitted by one of the classifications as an accompanying characteristic, which excludes about 70% of cases. According to the consensus, an arbitrary number of episodes and at least two migraine characteristics are required for diagnosis. The estimated duration of the episodes is one or two hours, although there are studies that show that the establishment of arbitrary time periods involves high other episodes of shorter duration.
It is worth suspecting the diagnosis of abdominal migraine even if not all consensus criteria are met; patients often have other accompanying episodic syndromes that were excluded from the consensus.
Table 1
Recommended clinical definition of abdominal migraine based on diagnostic criteria, published evidence and experience of the authors - Episodic central abdominal pain lasting more than one hour. - The episodes occur with one or more of the following symptoms: paleness, anorexia, nausea, vomiting, photophobia, headache or are associated with other episodic syndromes, particularly cyclic vomiting, among others. -The person feels well between episodes -Physical examination and normal development |
| How common is abdominal migraine? |
Prevalence depends on the definition and diagnostic suspicion in the absence of an objective diagnostic marker.
In two English studies in children the prevalence was 4.1% and 2.4% using the 1986 definition, using the Rome III diagnostic criteria the prevalence was 9.2% in a survey study of mothers of 949 American children, the prevalence in An English study in children aged 6 to 12 years was 9% at age 12 and decreased to 1% at age 14 with a female-male ratio of 1.6:1.
| What stimulates and relieves the pain of an abdominal migraine? |
Stress, fatigue, travel, skipping meals, and changes in routine can trigger abdominal migraines in the same way as all migraines.
Sometimes triggers can be mistaken for aura symptoms, for example, bright lights and low mood when they are actually aura symptoms.
The factors that relieve migraines are, as with other types of migraines, rest in 88% of patients, sleep in 64% and pain relievers in 38%.
| How do I diagnose an abdominal migraine? |
Consensus suggests that patients with a firm diagnosis of abdominal migraine do not require further studies.
Typically a child with abdominal migraine presents to the office or emergency room with the characteristics described in Table 1, the challenge is to distinguish between organic and other functional causes of recurrent abdominal pain using clinical characteristics and ruling out red flags ( “red flags”).
Red flags suggest organic causes of abdominal pain and require referral of these children for immediate medical consultation. The approach is complex in children under 2 years of age who may not be skilled at explaining or pointing out the pain. In these patients, the pain can be inferred from uncontrollable crying or the retraction of the legs on the abdomen.
Patients with abdominal migraine often have a family history of other types of migraines, similar undiagnosed episodes, or other episodic syndromes.
The physical examination, including vital signs and urinalysis, is normal beyond vasomotor changes (paleness, dark circles). Urinalysis is an important part of the physical examination since patients with diabetic ketoacidosis or urinary infections may present with pain. abdominal.
If a child diagnosed with abdominal migraine presents with pain on duty or at the office, it is necessary to re-examine the patient, specifically if there are new or atypical symptoms or signs that may suggest an intercurrence.
Outside of abdominal migraine, other neurological causes of abdominal pain are rare. In abdominal epilepsy the pain is usually short (seconds to minutes) and is associated with alterations in the level of consciousness and sometimes followed by a tonic-clonic seizure.
Consensus suggests that those patients with a firm diagnosis of abdominal migraine do not require further studies.
| What causes abdominal migraine? |
They have been suggested as causes of abdominal migraines:
- Specific changes in the gut-brain axis
- Vascular dysregulation
- Changes in the central nervous system
- Genetic factors
It is not clear why some people are more vulnerable to the interaction between the central nervous system and the rich intestinal innervation and how this association with the trigeminal vascular system plays a primary role in cerebral migraine.
No studies suggest vascular spasms of the intestine as a cause of periumbilical pain, but regional or central changes in flow could be important as in other forms of migraines. The genetic role is important, particularly for mutations affecting membrane transporters.
| What other conditions is abdominal migraine associated with? |
In population studies, 70% of patients with abdominal migraine have or have had cerebral migraines with or without aura, patients with abdominal migraines often have other prior or concurrent syndromic episodes particularly cyclic vomiting and limb migraines, other associations Possible causes are benign paroxysmal vertigo, benign paroxysmal torticollis, infant colic, Raynaud’s disease and intestinal hypermotility.
Avoid assuming that abdominal pain in children without an organic cause has a psychogenic basis
| Is abdominal migraine associated with mental health? |
Avoid assuming that abdominal pain in children without an organic cause has a psychogenic basis, it is postulated to be associated with depression, anxiety, psychosocial difficulties and abuse. Some studies were carried out in uncontrolled and non-representative populations, have only control groups without pain, and homogeneously associate all abdominal pain as functional or underestimate the variability of pediatric anxiety and depression.
Controlled studies show that pain is associated with psychological stress in children, adults and families regardless of the cause or location, levels of depression and emotional disturbances were similar in children with functional abdominal pain and in children without pain with minor illnesses. Mood change as a premonitory or postdromal symptom is recognized in outpatients with migraine, but there is no specific information on its prevalence in abdominal migraine.
| What happens to children with abdominal migraine as they grow? |
They usually have an excellent prognosis without developmental or neurological deficits. A longitudinal study of 54 children showed that the diagnosis of abdominal migraine was conclusive and resolved in 61% of the children at 8 to 10 years of follow-up,
The prevalence and prognosis of abdominal migraine in adults is unknown with evidence limited to case reports and small series of patients.
| How are children with abdominal migraine managed? |
• General and psychosocial approaches
A clear diagnosis and explanation of the condition to the family is essential. In an observational clinical study, 60% of patients had parents with the same pathology who also felt relieved to understand it.
Labeling a patient with the diagnosis of abdominal migraine as a medically unexplained pathology or as pain with a psychogenic cause only increases the anxiety and depression of children and their caregivers. In case series from hospitals in India and England, 4 to 5% of patients with abdominal migraine undergo unnecessary surgery (appendectomies) due to diagnostic errors.
The biopsychosocial model of pain and symptom management emphasizes a holistic view of the patient’s life; behavioral therapies improved the behavior of functional abdominal pain in controlled series but there are no data for abdominal migraine. Exclusion diets or dietary treatments are not approved.
It is helpful to avoid triggers (emotional stress, eating disorders, and loss of sleep); in more than 80% of patients, acute symptoms disappear with rest in a dark room and simple analgesia.
• Pharmacological approaches
The evidence for pharmacological treatment of abdominal migraine is limited. In studies of migraines with headache in the pediatric population, pain resolution rates with placebo reach 66%, which is why quality randomized controlled studies are needed to confirm the effectiveness of active treatments. Pizotifen is the only medication that meets the standards for abdominal migraines.
Acute treatments and preventive treatments (if necessary) can be managed in primary care and are effective in most patients. The use of other medications requires indication by specialists since information is limited or absent regarding their use for the treatment of abdominal migraine.
It is unknown whether the evidence for the treatment of acute and preventive pain of cerebral migraine can be extrapolated to the management of abdominal migraine; in the case of adults the only evidence available for the treatment of abdominal migraine is from case reports.
