Abdominal migraine

Shuu-Jiun Wang MD (Dr. Wang of the National Yang-Ming University School of Medicine and the Neurological Institute, Taipei Veterans General Hospital received consulting fees from Eli Lilly.)
Originally released February 14, 1994; last updated September 24, 2017; expires September 24, 2020

This article includes discussion of abdominal migraine, migraine with abdominal pain, and recurrent abdominal pain of childhood. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

In this article, the author updates new findings for abdominal migraine as well as for a condition referred to as cyclic vomiting syndrome. This update includes a survey done in the emergency departments in Italy and France on children and adolescents (ages 6 to 17). Compared with controls, patients with migraine but not tension-type headache were associated with a higher chance to have functional dyspepsia (odds ratio (OR)=10.76), abdominal migraine (OR=5.87), and irritable bowel syndrome (OR=3.47).

Key points

 

• In 2013, the International Headache Society published new diagnostic criteria of abdominal migraine and cyclic vomiting in the International Classification of Headache Disorders, third edition (beta version).

 

• Abdominal migraine is recognized as the migraine equivalent of infancy, childhood, and adolescence and is often underdiagnosed in those with chronic, idiopathic, and recurrent abdominal pain.

 

• Abdominal migraine, as well as cyclic vomiting, is recognized as a periodic paroxysmal syndrome without associated headache, which is thought to be migrainous in etiology.

 

• Three abdominal pain-related functional gastrointestinal disorders including abdominal migraine, functional dyspepsia, and irritable bowel syndrome are associated with migraine in children and adolescents.

 

• Acute and preventive migraine medications are found to be effective in some patients with abdominal migraine or cyclic vomiting syndrome.

Historical note and terminology

"Gastric, uterine, and ophthalmic" were the "3 principal varieties of sympathetic or eccentric megrim" considered by Liveing to arise by peripheral stimulation of the nervous system (Liveing 1873). Liveing cited Fothergill's gastric megrim, which he described as a condition induced by melted butter, fat, spices, rich dishes, or malt liquors causing secretions of "acid bile." Evidently, dietary, menstrual, and ophthalmic migraine were recognizable 120 years ago. But Liveing went further, believing that "metamorphic and vicarious relations" of migraine included epilepsy ("the closest connection"), asthma, gout, angina, and tic douloureux. His analytical table shows that 3 of his 60 patients had abdominal pain (gastralgia) replacing headache in some attacks, although abdominal pain is not mentioned in his detailed description of migraine episodes.

Abdominal pain that adults experience in the absences of headache was described by Buchanan in 1921 (Buchanan 1921), but the term “abdominal migraine” was not introduced until the following year (Brams 1922). Under the term "migraine equivalents," Wolff noted that attacks of migraine headache and associated symptoms may be replaced by periodic disturbances of other somatic symptoms, including abdominal pain or recurrent attacks of vomiting, diarrhea, or transient mood disorders (Wolff 1963). The list of somatic symptoms was extended by Rose to include vertigo, cardiac migraine, and transient global amnesia (Rose 1986). Graham and Selby expressed some doubts concerning this concept, although the latter thought that some children did have abdominal migraine (Graham 1955; Selby 1983).

“Abdominal migraine" causes great controversy among headache experts (Hackaday 1992; Symon 1992). Some authors insist that recurrent abdominal pain can be diagnosed as abdominal migraine only when patients have migraine concurrently or develop migraine thereafter. Some authors cast doubt on the existence of the diagnostic entity. In fact, approximately 10% of children have recurrent abdominal pain (Bury 1987), but the prevalence of migraine in the age group of 7 to 9 years is less than 3% (Bille 1962), which means that most children with recurrent abdominal pain do not have abdominal migraine. It must be noted that abdominal pain is a not a common feature of migraine in children or adults. Writing about migraine equivalents in children, Hockaday and Barlow warn that: "When such episodes consist only of rather nonspecific symptoms such as nausea, vomiting, abdominal discomfort, or bowel change, there must always be considerable doubt about its nature" (Hockaday and Barlow 1993).

In fact, abdominal migraine was not adopted in the criteria of the first edition of the International Classification of the Headache Disorders (ICHD-I) (International Headache Society 1988). However, studies suggest its existence and call for a definition to differentiate it from other recurrent abdominal pain syndromes (Symon and Russell 1986). In 2004, the second edition of the International Classification of Headache Disorders (ICHD-II) for the first time included abdominal migraine (code 1.3.2) as 1 of the 3 “childhood periodic syndromes that are commonly precursors of migraine” (code 1.3). The other 2 syndromes are cyclic vomiting (code 1.3.1) and benign paroxysmal vertigo of childhood (code 1.3.3). These recognized migraine equivalents of infancy, childhood, and adolescence are recognized periodic paroxysmal syndromes without associated headache that are thought to be migrainous in etiology. The criteria for abdominal migraine are in the following, which are similar to those proposed by Abu-Arafeh and Russell (Abu-Arafeh and Russell 1995a).

In 2013, the third edition of the International Classification of Headache Disorders (ICHD-III), beta version, was published. “1.3 Childhood periodic syndromes that are commonly precursors of migraine” was renamed “1.6 Episodic syndromes that may be associated with migraine.” In addition, abdominal migraine (code 1.6.1.2) (Table 1) and cyclic vomiting (code 1.6.1.1) are included in 1.6.1 Recurrent gastrointestinal disturbance (Headache Classification Committee of the International Headache Society 2013).

Table 1. Diagnostic Criteria of Abdominal Migraine (ICHD-III, beta version)

A. At least 5 attacks of abdominal pain, fulfilling criteria B to D
B. Pain has at least 2 of the following 3 characteristics:

 

1. Midline location, periumbilical or poorly localized
2. Dull or “just sore” quality
3. Moderate or severe intensity

C. During attacks, at least 2 of the following occur:

 

1. Anorexia
2. Nausea
3. Vomiting
4. Pallor

D. Attacks last 2 to 72 hours when untreated or unsuccessfully treated
E. Complete freedom from symptoms between attacks
F. Not attributed to another disorder

(Headache Classification Committee of the International Headache Society 2013)

Table 2. Diagnostic Criteria of Abdominal Migraine (Rome III Pediatric Criteria)

Must include all of the following:

1. Paroxysmal episode of intense, acute periumbilical pain that lasts 1 hour or more
2. Intervening periods of usual health lasting weeks to months
3. The pain interferes with normal activities.
4. The pain is associated with 2 or more of the following:

 

A. Anorexia
B. Nausea
C. Vomiting
D. Headache
E. Photophobia
F. Pallor

5. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process considered that explains the subject's symptoms

Note: Criteria fulfilled 2 or more times in the preceding 12 months

(Rome III Functional Gastrointestinal Disorder Child/Adolescent Committee 2006)

The new criteria make abdominal migraine a well-defined type of recurrent abdominal pain; that is, abdominal migraine is only 1 type of recurrent abdominal pain, which has a strong relationship with migraine. In addition, the proposed Rome III pediatric criteria for functional gastrointestinal disorders addressed 3 clinical entities for functional gastrointestinal disorders in children aged 4 to 18 years (Rasquin et al 2006): H1 (vomiting and aerophagia), H2 (abdominal pain-related functional gastrointestinal disorder), and H3 (constipation and incontinence). Abdominal migraine was classified as 1 of the abdominal pain-related functional gastrointestinal disorders under this symptom-based classification. The Rome III pediatric criteria for abdominal migraine (Table 2) were similar to the ICHD-III-beta criteria except that in the Rome III criteria 2 episodes were sufficient to fulfill the diagnosis, whereas in the ICHD-III-beta criteria at least 5 episodes were required. Besides, the Rome III pediatric criteria also included headache as 1 of the relevant symptoms. Family history of migraine and a history of motion sickness were recognized as supportive criteria. The difference between the ICHD-III-beta and the Rome III pediatric criteria should spur any clinician to investigate this disorder from different aspects, even though the essence of the criteria is somewhat similar. Further studies based on these criteria will not only validate the criteria, but also clarify the dispute regarding the existence of the disease entity. Nonetheless, the new criteria were being field-tested clinically. It was demonstrated that the Rome III criteria had better yield in diagnosing abdominal migraine among 368 pediatric patients with chronic abdominal pain without organic lesions than the previous Rome II criteria (Baber et al 2008).

A Norwegian study also supports the finding that the Rome III criteria provide clinicians with an important tool in their approach to children with abdominal pain (Helgeland et al 2009). However, this study also points out that there is a significant overlap between different functional gastrointestinal disorders (eg, 33% of children with irritable bowel syndrome also had a diagnosis of abdominal migraine), and it raises a concern that some diagnoses in the Rome III criteria might actually be common symptoms of functional gastrointestinal disorders rather than distinct disorders.

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