Abdominal Migraine (Abdominal Migraine (context Dependent Category))

Abdominal migraine (AM) is a particular type of migraine, in which the neurological disorder is associated with abdominal pain.

The disorder originates from the following process: endocrine.

Presentation

AM usually manifests itself with an acute, severe and midline abdominal pain which is usually associated with nausea and emesis. The subject clearly appears pale and completely unable to eat. The attacks of abdominal pain usually last from 1 to 72 hours, and generally the pain has a midline or periumbical location, with a dull or sore quality and moderate to severe intensity. During an attack of abdominal pain the patient presents with at least two of the following signs, the already mentioned emesis, nausea, and pallor together with anorexia. Pain might sometime be so severe to interfere with the patient’s daily life and pallor might frequently be accompanied by dark shadows under the eyes. In some cases flushing can occur, persisting as predominant vasomotor phenomenon. It is important to remember that many children affected by AM will develop migraine headache later in life.

Workup

Diagnosing AM might be a problematic task since children find it difficult to recognize and distinguish the typical signs of this disorder from those of other gastrointestinal illnesses [9]. Therefore, the first step in the diagnosis is to exclude the possibility of other causes for the abdominal pain.

Once other possible origins are eliminated, the presence of the major clinical signs of AM should be examined. The pain itself should be moderate to severe, and in general its duration should vary between one to 72 hours. Together with the important signs of nausea and vomiting, anorexia should appear as well, especially in terms of decreased appetite and the already mentioned inability to eat.

Pallor is the main feature of the subject’s physical appearance, that should not involve just the face, but the entire skin of the body, appearing abnormally and predominantly pale in color. In addition to this, a marked flushing on the face together with possible dark shadows under the eyes may be present. Furthermore, the subject should show frequent yawning, tendency to listlessness and marked drowsiness possibly coupled with the moderate to severe headache.

Treatment

The treatment of AM is based on two major component, reducing the intensity of symptoms and preventing future attacks. Over the years many medications have been developed for treating symptoms and preventing this disorder, whose clinical response vary in different degree according to the affected individuals. Therefore, it is up to the physician to choose the right medication. Some of the drugs used to treat AM include:

  • Sumatriptan: A member of the triptan class which is generally used to treat migraine in adults.
  • Tricyclic antidepressants: Used to block the effects of serotonin and thus decrease the frequency of migraine attacks.
  • Analgesic drugs: Particularly nonsteroidal anti-inflammatory drugs (NSAIDs), even though one has to pay attention to their side-effects, especially the cardiovascular and liver complications [10] [11].
  • Low dose aspirin and low dose beta-blockers: Particularly used in long-term treatments to decrease frequency of attacks.
  • Antiseizure medications: Like valproic acid.
  • Ergomtine drugs: Frequently used to treat a large number of migraine variants.
  • Antihistamines: Cyproheptadine which appears to be very effective when used in children.

Treatment of AM is also based on recognizing and avoiding triggers, especially food which in some case has been identified as triggering factor. Since AM might have psychological and behavioral factors, it is highly recommended to add programs of stress management and relaxation in the treatment.

Prognosis

In the majority of the cases, children affected by AM will still have migraine in adulthood, and there is an increasingly larger evidence suggesting that AM might cause permanent disturbances if not properly treated on time. This is the reason why AM should be diagnosed very early, so that further damage can be avoided, and the sooner the diagnosis is made the better. Furthermore, it is very easy to mistake AM with some other diseases formulating wrong diagnoses which might even worsen the pathological conditions. Therefore, it is paramount for the doctors to rule out any other possible cause of the signs and symptoms observed.

Etiology

The etiology of AM still remains unknown. A great number of experts backs the theory for which AM is the result of marked fluctuations in the biochemical balance between two important neurotransmitters, histamine and serotonin. Therefore, the pathology might be neurological in origin, but then ends up involving the abdominal area as a result of the biochemical condition previously indicated.

According to another theory, instead, always largely backed by many experts, AM is the pathological result of the excess of nitrites contained in certain foods such as chocolate, Chinese food or processed meat. From this point of view, the physiological unbalance underlying AM does not come from noxious stimuli, such as stress and anxiety, but from the diet followed by the subjects.

Epidemiology

AM as chronic and recurrent abdominal pain occurs in 9-15% of the pediatric population. According to The American Academy of Pediatrics Subcommittee on Chronic Abdominal Pain and North American Society of Pediatric Gastroenterology, Hepatology and Nutrition, AM is one of the most common abdominal pain affecting children [3]. The disorder is much more common among those with a family history of migraine headaches and generally tends to appear for the first time very early in life, between the ages of 3 and 10 years [4].

As previously said, AM is very rare in adulthood. However, there is an increasingly larger evidence which shows how AM tends to evolve into migraine headache, as though it may be a clinical precursor on migraine [5]. No particular predisposition of AM has been found between females and males, who appear to be equally affected by this disorder and to have a positive family history of migraines affecting first-degree relatives.

Sex distribution
Age distribution

Pathophysiology

There are several hypotheses which have been put forwards over the years to explain the pathophysiology and pathogenesis of AM, which entail the involvement of a plethora of different factors such as IgE-mediated diet-induced allergy, phenol sulfotransferase enzyme M and P catabolism of catecholamines and monoamines, or the immune response of gut mucosal and the permeability of its surface [6]. In any case, the most widely accepted theory involves a strict relationship between the gut and the central nervous system [7], which tend to have direct effect on each other especially in very stressful conditions, through the action of histamines and serotonins. In other words, the stress accumulated over time increases the secretion of these key neurotransmitters, which in turn cause the dysregulation of the digestive system and the appearance of all the typical signs and symptoms of this disorder. Since the occurrence and intensity of AM pain might be influenced by mental, emotional, and behavioral factors, it is considered a classical example of functional pain [8].

Prevention

A key element in preventing AM is to figure out what are the factors triggering the episodes and to avoid them as much as possible. This could be achieved by appropriately educating the patients on the proper prevention plans that have to be adopted. The preventive measures should be based on the right diet, especially in the cases where pain is triggered by particular types of foods, as well as effective self-managing stress plans and healthy lifestyle habits. For this purpose, the patients are recommended to keep a personal diary recording all AM episodes and consult the doctor to organize the appropriate plan of action.

Summary

Although abdominal migraine (AM) can occur at any age, it is much more frequent in children than in adults. Since many of the its signs are non-specific, it is very difficult to diagnose AM, unless further investigations are made. In any case, an episode entails an intense abdominal pain which is coupled with other symptoms largely related to the digestive tract.

The name might be misleading, because although migraine is a term classically referring to a type of headache, AM is a type of chronic and recurrent abdominal pain not always associated with headache itself [1] [2].

Patient Information

Abdominal migraine (AM) is a particular type of migraine, in which the neurological disorder is associated with a pain in the belly, usually near the navel. Although it can occur at any age, AM is much more frequent in children than in adults. An episode entails an intense abdominal pain which is coupled with other symptoms largely related to the digestive tract. In the majority of the cases children affected by AM will still have migraine in adulthood, and there is an increasingly larger evidence suggesting that AM might cause permanent damage if not properly treated on time. 

The cause of AM still remains unknown, but a great number of experts believe that this disorder is caused by a dysfunction if the relationship between the digestive and nervous system. AM usually manifests itself with an acute, severe abdominal pain which is usually associated with nausea and vomiting. The patient appears pale and completely unable to eat. As rule, the attacks last from 1 to 72 hours, and generally the pain is located around the navel, with a dull or sore quality and moderate to severe intensity. The pain might sometime be so severe to interfere with the daily life and the pale skin might frequently be accompanied by dark shadows under the eyes. In some case flushing can also occur. 

A key element in preventing AM is to figure out what are the factors triggering the episodes and try to avoid them as much as possible. The preventive measures should be based on the right diet, especially in the cases where pain is triggered by particular types of foods, as well as effective self-managing stress plans and healthy lifestyle habits. A number of drugs are also available to treat the condition. 

Self-assessment

References

  1. Russell G, Abu-Arafeh I, Symon DN. Abdominal migraine: evidence for existence and treatment options. Paediatric drugs 2002 4 (1): 1–8.
  2. Cuvellier JC, Lépine A. Childhood periodic syndromes. Pediatric neurology 2010 42 (1): 1–11.
  3. Di Lorenzo C. Chronic abdominal pain in children: A technical report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition: AAP Subcommittee and NASPGHAN Committee on Chronic Abdominal Pain. J Pediatr Gastroenterol Nutr. 2005;40:249-261.
  4. Mortimer MJ, Kay J, Jaron A. Clinical epidemiology of childhood abdominal migraine in an urban general practice. Dev Med Child Neurol. 1993; 35:243-248.
  5. Dignan F, Abu-Arafeh I, Russell G. The prognosis of childhood abdominal migraine. Arch Dis Child. 2001;84:415-418.
  6. Bentley D1, Kehely A, al-Bayaty M, Michie CA. Abdominal migraine as a cause of vomiting in children: a clinician's view. J Pediatr Gastroenterol Nutr. 1995;21 Suppl 1:S49-51.
  7. Weydert JA, Ball TM, Davis MF. Systematic review of treatments for recurrent abdominal pain. Pediatrics. 2003 Jan;111(1):e1-11.
  8. Noe JD, Li BU. Navigating recurrent abdominal pain through clinical clues, red flags, and initial testing. Pediatric annals 2009 38 (5): 259–66.
  9. Davidoff RA. Migraine : manifestations, pathogenesis, and management (2nd ed.). Oxford [u.a.]: Oxford Univ. Press. p. 81. 2002
  10. Wen-Yi Shau, Hsi-Chieh Chen, Shu-Ting Chen, Hsu-Wen Chou, Chia-Hsuin Chang, Chuei-Wen Kuo, and Mei-Shu. Risk of new acute myocardial infarction hospitalization associated with use of oral and parenteral non-steroidal anti-inflammation drugs (NSAIDs): a case-crossover study of Taiwan's National Health Insurance claims database and review of current evidence. BMC Cardiovasc Disord. 2012; 12: 4. Published online 2012 Feb 2.
  11. John L Wallace. Mechanisms, prevention and clinical implications of nonsteroidal anti-inflammatory drug-enteropathy. World J Gastroenterol. 2013 Mar 28; 19(12): 1861–1876. 

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Self-assessment