Recurrent Abdominal Pain in Children May Be Migraine

From Medscape Medical News > Neurology
Pauline Anderson

May 5, 2011 — Up to 15% of recurrent abdominal pain in children meets criteria for abdominal migraine (AM), a new study suggests.

The findings underline the importance of recognizing AM in children with recurrent abdominal pain because there are now a wide range of treatments available, researchers say.

"The message is that this is out there," said Donald Lewis, MD, professor of pediatrics and neurology at Children's Hospital of the King's Daughters and Eastern Virginia Medical School in Norfolk. "US physicians just aren't thinking about it, aren't recognizing it, and there are kids with recurrent abdominal pain who might benefit from the interventions we have for migraine."

The study appears in the May issue of the journal Headache.

Family History

The retrospective study included 458 male and female subjects aged 1 to 21 years with idiopathic recurrent abdominal pain who were evaluated at the Pediatric Gastroenterology Clinic at the Children's Hospital of the King's Daughters in Norfolk. None of these children were identified as having AM by clinic physicians.

The study showed that of the 458 patients, 50 (11%) met criteria for "probable" AM, meaning that they lacked at least 1 criterion, and 20 patients (4.4%) met formal criteria for AM.

Of all 458 patients, 75% had a family history of recurrent abdominal pain and 46% had a family history of migraine, but of those who met formal criteria for AM, 62.5% had a family history of migraine.

A personal history of migraine was noted in 15% of all subjects but in 38% of the children who met formal AM criteria. This, said the study authors, indicates that it is 4 times more likely for patients with recurrent abdominal pain to have AM if they also have migraine headache (95% confidence interval, 1.56 – 11.92; P < .024) In 2004, the International Headache Society included AM among its "periodic syndromes of childhood that are precursors for migraine," the study authors note. Genetic Link? Although the link between childhood abdominal pain and adult migraine headache isn't exactly clear, experts hypothesize that the gene for migraine may not yet be expressed completely in childhood. "There are lots of examples of disorders that begin in childhood but don't have the full-fledged manifestations," said Dr. Lewis. He noted that the brainstem, where "revved up" circuits can cause the pain of migraine, are adjacent to the centers for vomiting and nausea. In this study, young patients suspected of having AM were more likely to have nausea, vomiting, and anorexia. To date, the overwhelming body of literature pertaining to AM comes from Europe, primarily Scotland. In the United States, children with recurrent abdominal pain are typically referred to gastroenterologists, who explore organic causes and rarely consider migraine, said the study authors. Lack of Training AM is not typically covered in medical school residency programs, added Dr. Lewis. "When you find a gap in the education like this, you've got to fill it." Most gastrointestinal physicians are capable of managing pediatric AM, although "it opens up an armamentarium of treatments they really hadn't considered," said Dr. Lewis. Research shows that ibuprofen and acetaminophen are useful in managing migraine without aura in young children, although there are no data on these agents in AM. Similarly, there are no data on the use of triptans for AM. There is evidence, however, that pizotifen, propranolol, and cyproheptadine may prevent recurrent attacks. Anecdotal evidence indicates that other strategies used to treat migraine headache — for example, getting regular exercise, eating regular meals, getting enough sleep, and avoiding triggers, such as chocolate and caffeine — are also useful in AM. Dr. Lewis said that about one-third of migraines are triggered by a food.

Sometimes just telling a teen to eat breakfast or to exercise every day helps, he added.

For children with AM who are genetically predisposed to get migraines, changing lifestyle habits, using medications judiciously, and avoiding triggers may help reduce disability later in adulthood, at least to some degree, said Dr. Lewis. "There's no evidence to back that up, but it makes sense."

Physicians should also ask about a family history of migraine. "It's not a formal criteria for AM, but I think it's a supporting bit of history," as is the episodic nature of the attacks, said Dr. Lewis.

Alert Physicians

Asked for a comment, Michael Goldstein, MD, Western Neurological Associates, Salt Lake City, Utah, and previous vice president, American Academy of Neurology, said the study will alert physicians that some children with unexplained abdominal pain may respond to treatment for migraine.

However, the study does not show that children who fulfill the criteria for AM have migraine or that treatment for migraine will improve their symptoms.

The next and possibly more important step would be to show that children with abdominal pain who fulfill criteria for abdominal migraine are improved when treated for migraine.

"The study helps highlight a possible cause for abdominal pain but is only a first step in helping these children," he wrote in an email to Medscape Medical News.

"The next and possibly more important step would be to show that children with abdominal pain who fulfill criteria for abdominal migraine are improved when treated for migraine."

Dr. Goldstein noted that amitriptyline, which has been shown to help patients with migraine, is commonly used for children with unexplained abdominal pain.

The study authors have disclosed no relevant financial relationships.

Headache. 2011;51:707-712. Abstract