Your 3:30 appointment is a 10-year-old boy, whom you’ve never met, with a chief complaint of “stomach pain.” You head to the exam room knowing this may be a 5-minute visit, but fearing that it may be a 45-minute visit.
Your patient is quietly sitting on the exam table in no distress playing a game console, and for a moment you think this may be easy. Then you get the history.
For the past 2 to 3 years, this young man has been plagued with repeated midline stomach pains, which (once he turns off his game) he describes as dull and achy. The pain is associated with nausea and usually vomiting. The vomitus is non-bloody, non-bilious. He denies diarrhea or other stool changes. He has a normal appetite between bouts, but has no appetite when he is in pain. He denies increased belching or sour brash. The pain is bad enough for him to miss school. His mother adds that he looks “drained” when he is ill.
He saw one of your partners several months ago who referred him to a gastroenterologist.
His work up has included CBC and differential, sedimentation rate, liver function tests, electrolytes, amylase and lipase, stool guaiac, urinalysis, a workup for celiac disease, and Mono and Hepatitis screens—all normal. He has had an upper GI with small-bowel follow through, a barium study, an abdominal ultrasound, endoscopy and a colonoscopy—again all normal.
His mother is frustrated and sure it must be some kind of cancer.
This patient has abdominal migraines. But how do you make that diagnosis? Could you have made the diagnosis sooner?
Between 9% and 15% of children complain of recurrent abdominal pain. Most cases are attributed to functional abdominal pain, defined as “chronic, idiopathic abdominal pain without anatomic, infectious, metabolic or inflammatory cause.”
This broad category includes 4 distinct diagnoses2:
• Functional dyspepsia (functional abdominal pain or discomfort in the upper abdomen)
• Irritable bowel syndrome (functional abdominal pain associated with alteration in bowel movements3)
• Abdominal migraine (see below)
• Functional abdominal pain syndrome (functional abdominal pain without the characteristics of dyspepsia, irritable bowel syndrome, or abdominal migraine3)
Abdominal migraine is defined by the International Classification of Headache Disorders Version 2 or ICHD II 4:
1.3.2 Abdominal Migraine
An idiopathic recurrent disorder seen mainly in children and characterized by episodic midline abdominal pain manifesting in attacks lasting 1 to 72 hours with normality between episodes. The pain is of moderate to severe intensity and associated with vasomotor symptoms, nausea, and vomiting.
Diagnosis criteria:
A. At least 5 attacks fulfilling criteria B-D
B. Attacks of abdominal pain lasting 1 to72 hours (untreated or unsuccessfully treated)
C. Abdominal pain has all of the following characteristics:
1. midline location, periumbilical or poorly localized
2. dull or ‘just sore’ quality
3. moderate or severe intensity
D. During abdominal pain at least 2 of the following:
1. anorexia
2. nausea
3. vomiting
4. pallor
E. Not attributable to another disorder . . .
Most children with abdominal migraine will develop migraine headache in later life.
Let’s return to our patient. One key component of his history was missed . . . his family history. When asked, our patient’s mother states that she has had severe “menstrual headaches” for years. She describes photophobia and nausea with her headaches. At times, she takes Fioricet when she gets these headaches.
In any migraine disorder, the family history is vital. Migraines usually run in families. I tell my patients (only slightly tongue-in-cheek) that for every 100 patients I see with migraines, 80 tell me that someone on their mother’s side has headaches, 15 tell me that someone on their father’s side has headaches, and the other 5 are misinformed. In fact, Nelson’s Textbook of Pediatrics, quoted above, includes the statement “. . . as well as a maternal history of migraine headaches” in its description of abdominal migraine.3
On further questioning, you find that your patient often stays up to 1:00 AM playing video games and his abdominal pains are often associated with stressful events, such as school tests, family gatherings, or travel.
The usual patient with abdominal migraine is between 3 and 10 years old. Boys and girls are equally affected.1 Occasionally, patients will describe a prodrome or preceding aura; attacks can occur at regular intervals or they may be sporadic. Psychological stress, prolonged fasting, or lack of sleep may precipitate an attack.
Abdominal migraine affects 1% to 4% of the pediatric population and represents 4% to 15% of patients with functional abdominal pain.1 Although it can persist into adulthood,5 it usually resolves within 2 years.6 Seventy percent of those affected go on to have migraine headaches.5 Unfortunately, abdominal migraine remains a diagnosis of exclusion and it is not unusual for symptoms to go on for prolonged periods before the diagnosis is made.
There is limited evidence on therapy, but a few elements are clear. Lifestyle issues: poor sleep patterns, inconsistent eating habits, and stress need to be dealt with. Often, dealing with these issues alone will make a big difference in the patient’s life. Dietary measures can be explored, but are often difficult for the patient to comply with.
Migraine therapies such as sumatriptan(Drug information on sumatriptan) may be helpful but formal trials are lacking. Prophylaxis should be reserved for only severely affected patients whose lives are significantly affected. Here again, controlled studies are lacking, but medicines used for migraine headache prophylaxis may be considered.
In our patient and in most cases, a clear explanation of the diagnosis and a lifestyle discussion will often go a long way toward easing the burden of the disease.
References:
1. Carson L, Lewis D, Tsou M, et al. Abdominal migraine: an under-diagnosed cause of recurrent abdominal pain in children. Headache. 2011;51:707-712.
2. Di Lorenzi 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.
3. Kliegman R, Stanton B, Schor N, et al, eds. Nelson’s Textbook of Pediatrics. 19th ed. Philadelphia: Elsevier Saunders; 2011:1346-1349.
4. Headache Classification Committee. The international classification of headache disorders, cranial neuralgia and facial pain, 2nd ed. Cephalalgia. 2004;24(suppl 1):1-160.
5. Cuvellier J-C, Lepine A. Childhood pediatric syndromes. Pediatr Neurol. 2010;42:1-11.
6. Al-Twaijri WA, Shevell MI. Pediatric migraine equivalents: occurrence and clinical features in practice. Pediatr Neurol. 2002;26:365-368.
