David N K Symon

Abdominal migraine: evidence for existence and treatment options.

There is evidence to suggest that, in children, episodic abdominal pain occurring in the absence of headache may be a migrainous phenomenon. There are four separate strands of evidence for this: (i) the common co-existence of abdominal pain and migraine headaches; (ii) the similarity between children with episodic abdominal pain and children with migraine headaches, with respect to social and demographic factors, precipitating and relieving factors, and accompanying gastrointestinal, neurological and vasomotor features; (iii) the effectiveness of non-analgesic migraine therapy (such as pizotifen, propanolol, cyproheptadine and the triptans) in abdominal migraine; and (iv) the finding of similar neurophysiological features in both migraine headache and abdominal migraine.Abdominal migraine is rare, but not unknown, in adults. Many families are content with a diagnosis and reassurance that the episodes, though distressing, are not the result of serious pathology. Some patients respond to simple dietary and other prophylactic measures.There is scant evidence on which to base recommendations for the drug management of abdominal migraine. What little literature exists suggests that the antimigraine drugs pizotifen, propanolol and cyproheptadine are effective prophylactics. Nasal sumatriptan (although not licensed for pediatric use) may be effective in relieving abdominal migraine attacks.

Abdominal migraine: A childhood syndrome defined

It has long been recognized that some cases of recurrent abdominal pain in children are related to migraine, but the diagnostic criteria for abdominal migraine have not been defined. We have identified a group of children with recurrent abdominal pain who had a family history of migraine—in over half the cases in a first-degree relative—and who obtained marked relief from their symptoms from specific anti-migraine therapy. These children had a well-defined syndrome comprising episodes of midline abdominal pain of sufficient severity to interfere with normal activities and lasting for prolonged periods, frequently accompanied by pallor, headache, anorexia, nausea, and vomiting. It is proposed that these children have “abdominal migraine”.

The relationship between cyclic vomiting syndrome and abdominal migraine

Summary: Abdominal migraine and cyclic vomiting are both self‐limiting episodic conditions of children, with periods of complete normality between episodes. The clinical features of both syndromes show considerable similarity, and resemble those found in association with migraine headaches. It is proposed that cyclic vomiting is a condition related to migraine.

Points: 75 Deaths in asthmatics prescribed home nebulisers

district. Pelvic inflammatory disease actually became a less common finding at laparotomy, though women using intrauterine contraceptive devices, who were a low risk group for a history of pelvic inflammatory disease and the finding of pelvic adhesions, had equivalent rates of endosalpingitis. Given that ectopic pregnancy has been linked with lower socioeconomic groups, it may be that the massive increase in unemployment has had more than a small part to play in the change in the rate of this disease over the past few years.

Dangers of lumbar puncture.

Raised intracranial pressure (>20 torr) was confirmed in five by direct measurement in the intensive care unit with subarachnoid or subdural monitoring devices. While clinical diagnosis can be difficult, there are signs which should alert the clinician to the likely presence of raised intracranial pressure. These include poor response to pain, decerebrate posturing (extensor hypertonus), sluggishly reacting dilated pupils, abnormal respiratory pattern, bradycardia, and raised blood pressure. We agree that computed tomography can be helpful in showing the presence of cerebral oedema, hydrocephalus, or a space occupying lesion, but it cannot be used to ascertain whether intracranial pressure is raised or not. The only way to establish this is by direct measurement. The general paediatrician is understandably anxious not to delay the diagnosis and treatment of meningitis; and the contraindications to lumbar puncture have been frequently and heatedly debated.2 It is not clear whether outcome for severe childhood meningitis would be substantially changed were antibiotics to be started before lumbar puncture (but after blood culture and other rapid bacteriological tests) had been performed. What is becoming clear is that clinical history and examination cannot satisfactorily exclude acutely raised intracranial pressure (whether due to meningitis or not) in the child with rapidly advancing coma, for whom a lumbar puncture can have catastrophic consequences. Therefore, for these children lumbar puncture should be deferred until raised intracranial pressure can be excluded. Early admission to a paediatric intensive care unit with facilities for intracranial monitoring and computed tomography is recommended.

Abdominal migraine in children

Sir, Dr Tal and his colleagues ( l ) , on the basis of 4 cases, describe abdominal migraine as a “convenient and misleading diagnosis” and feel that this diagnosis should be regarded with some reserve, especially when headache is absent. In their paper they make no mention of the criteria used in making the diagnosis of abdominal migraine, and we would be hesitant in making the diagnosis on the basis of “just recurrent attacks of nausea and vomiting”, even with a family history of migraine. There is still a tendency to confuse abdominal migraine with other types of recurrent abdominal pain in children, although the syndrome has been described in detail on several occasions (2, 3, 4). We have studied over two hundred patients with abdominal migraine and feel that the diagnosis may be made with confidence ( 5 , 6). These children typically present with severe episodes of midline abdominal pain associated with marked pallor, anorexia and nausea and often accompanied by bilious vomiting (7). The pain is sufficiently severe to stop normal activities and commonly the child is sent home from school. It is of course difficult to establish the diagnosis of abdominal migraine during the first or even second attack of pain, before the recurrent nature of the condition becomes apparent. However, about 40% of these children also suffer from headache, which may be of diagnostic value, although the diagnosis may be made without headache. The concept of migraine without headache is well established (8). In the absence of headache, these patients are unlikely to present to a neurology clinic, which would account for the fact that the diagnosis was considered in only 5.5% of the cases reported by Tal et al. (1). In our experience as general paediatricians we see abdominal migraine as commonly as classical hemicrania. We do not agree with Tal et al. that the diagnosis of migraine is any less “secure” in childhood than in adult life. In the absence of any convenient laboratory test for the disease the diagnosis must rely on a careful clinical history.