What Is Abdominal Migraine?

The abdomen is considered that part of the body between the chest or thorax, limited by the diaphragm above and the edge of the peritoneal cavity in the lower abdomen.  Key organs such as the liver, the gall bladder, the pancreas, the uterus, the kidneys, the stomach and the upper and lower sections of the bowel are located there. Migraine is an inherited genetic chronic neurologic illness present in 25% of women and 6% of men that usually starts in the second decade between the ages of 10 and 20 years old and lasts into later adulthood for most persons.

Abdomen

Abdomen

The parasympathetic nervous system, that internal wiring of the body, not under direct voluntary control but in charge of automatically activating such parts of the body as the pupils which constrict when exposed to light via a reflex through the optic nerve and the midbrain.  Imagine going into bright sunlight and not having your pupils constrict.  It would be painful and way too bright.

Parasympathetic nervous system

Parasympathetic nervous system

Also imagine eating a cracker and not having your salivary glands automatically produce saliva.  It would be a very dry meal.  Thinking this way there are many autonomic functions that occur in our bodies daily, such as gastric acid production in the stomach in response to a cheeseburger, to digest the meat, sweating when we work out, partly to cool the body by the evaporation of the liquid, or peristalsis, which is the automatic movement of digested food to the small intestine and next to the large intestine and then out of the body in the toilet.

Overactivity of the autonomic nervous system can be a part of many medical conditions.  The autonomic fibers innervating cerebral arteries makes the arteries dilate, something that happens during a migraine headache.  All the sexual organs, erection, ejaculation, are governed by the autonomic nervous system.

Migraine makes all of cranial senses inflamed.  Persons with migraine have osmophobia, inflammation on the first cranial nerve, the olfactory nerve by various smells-cigarette smoke, fragrances, make a migraine headache worse.  Migraine patients have photophobia-fear of light during their attacks which involves the retina and second cranial nerve, the optic nerve.  Migraine patients may also have sonophobia, fear of sound through involvement of the eighth cranial nerve, the auditory nerve.  Migraine also turns on the chemoreceptive vomit center located in the medulla.

Cranial nerves

Cranial nerves

Migraine inflames or turns on the trigeminal nerve, the fifth cranial nerve which carries pain and touch and temperature to the top of the head, forehead, cheeks, and lower jaw.  These are areas where migraine strikes and hurts.

Although exactly what happens in the body with abdominal migraine is not clear, it has to involve a lot of the features as mentioned above.  Abdominal migraine patients have nausea, like migraine patients have.  The have paleness which is like blanching or vasoconstriction of the arteries in the face which happens with syncope or fainting and is an autonomic symptom.  Abdominal migraine patients have central abdominal pain around the umbilicus along with diarrhea which can also occur with migraine patients but is activation of peristalsis and emptying of the bowel which happens with abdominal migraine.

Also, abdominal migraine patients improve when treated acutely with triptans, like sumatriptan, or rizatriptan, indicating blocking of the release of the neurochemicals-Neurokinin A, substance P, and CRGP just like migraine patients do.  Abdominal migraine patients improve with usual old tried and true migraine preventive drugs like amitriptyline, propranolol, topiramate, and valproic acid.  I hope the new CGRP blockers, Aimovig, Emgality, and Ajovy will be found to work for abdominal migraine as well as they work for regular migraine.  It is too early now to know and there is no published data.

What Is Abdominal Migraine?  Abdominal Migraine is gastrointestinal or vasomotor, autonomic nervous system induced symptoms which occur in patients usually in the second decade of life, between 11 and 20 years old.  It is not associated with severe migraine headache but may come with mild headache at this young age.  Patients complain of nausea, vomiting, stomach cramping, vague centrally located abdominal pain around the umbilicus, and anorexia. 

Like big grown up migraine which occurs three times more often in women than men, more young adolescent girls have abdominal migraine than men.  Then later in her young twenties the GI symptoms and mild headache turns into more typical migraine headaches with associated nausea and vomiting.

Migraine activates the autonomic nervous system which controls arterial tone, gastric acid secretion, and GI motility.  Abdominal migraine may be called a “migraine equivalent.”

Abdominal migraine comes in recurrent attacks of midline abdominal pain which is “dull” or “sore” and which lasts 1-72 hours.  Migraine without aura is described by the International Classification of Headache Disorders-3 as lasting 4 to 72 hours, a similar time to the duration of the GI symptoms of abdominal migraine.  The migraine process releases neurochemicals in the brain that stay in the body up to 3 days, ultimately passing from the brain to the liver to be metabolized and then out in the toilet.

The abdominal pain is moderate or severe intensity and associated with nausea and vomiting.  Headache is absent or not very prominent at this age.  The attacks come in episodes and the patient is symptom free between attacks.

Related questions.

1.Is abdominal migraine related to regular adult age migraine?

Yes, abdominal migraine is more common in children who have close relatives with migraine. One study found that more than 90 percent of kids with this condition had a parent or sibling with migraine.  Two % of all children may develop abdominal migraine.

Turning it around, abdominal migraine is rare in adults.  Most adults with migraine have prominent headache which is the first symptom to develop.  Nausea comes to adults with migraine about 30-60 minutes after the pain starts.  Adults with migraine don’t usually have only GI symptoms without headache, or with mild headache. 

2.What are the symptoms of abdominal migraine?

Nausea

Vomiting

Pain occurs in the midline abdomen near the umbilicus.

Pain is described as “dull” or “sore”.

Pain is moderate or severe.

(Remember children are usually not great historians.  They may just double up in a ball and say, “My tummy hurts.”)

Pallor-pale skin

Anorexia-loss of appetite

Photophobia-sensitivity to light

Inactivity-the child doesn’t want to be up, but stays lying down, feels drowsy, or goes to sleep.

Nausea and vomiting

Nausea and vomiting

3.What is the duration of attacks of abdominal migraine?

Attacks are episodic, surrounded by normal health, and last 2-72 hours.  This is an interesting time period because the International Headache Association states that an attack or migraine may last 4-72 hours.  There is a sequence of events that occur during a migraine headache for an adult. 

The migraine timing cycle.  There are 4 steps in the migraine process.  The first step is trigeminal inflammation by the brainstem.  Then the second step at 20-40 minutes the ganglion of the nerve and artery in the brain start to release the Neuropeptides:  Neurokinin A, Substance P, and CGRP.  Then at about 2 hours the release of these chemicals causes the 3rd step--meningeal artery vasodilatation, and the 4th step at 3-4 hours is inflammation of the thalamus, a deep nucleus in the center of the brain which is called the “pain center” of the brain.  The 4th step is also called “Central Sensitization” because steps 1,2, and 3 occur in the skull but are outside the brain (trigeminal nerve, nerve and arterial ganglions, cerebral arteries.)  Step 4 inflames the thalamus, a deep nucleus inside the brain.

The Migraine Timing Cycle

The Migraine Timing Cycle

This cycle poorly developed in adolescents so that there is no or not much headache affects the autonomic nervous system and releases inflammatory neuropeptides that stay in the body 72 hours.  Although poorly understood these factors must be operant in abdominal migraine in adolescents.

I remember the words I heard when I was a 3rd year medical student on my neurology rotation that abdominal migraine occurred in an “immature brain with some but not all of the fully developed adult migraine features.”

4.What does the neurologic exam of a child with abdominal migraine reveal?

Well, very little actually.  Except for being pale, appearing sick, dull, and drowsy, there should be a non-focal neurologic exam-no toe sign, normal reflexes, supple neck, normal nontender abdomen, quiet abdominal signs, normal fundi.

There are no neurologic physical findings with abdominal migraine.

Checking the knee jerk

Checking the knee jerk

5.What are the results of blood work, CAT or MRI scan, electroencephalogram (EEG)?

All tests should be normal, unless the child has vomited enough to be dehydrated and change his electrolytes.  Dehydration is a deficiency of water in the body.  Dehydration makes the child feel thirsty.  The body conserves water by sweating less and excreting less urine.  The child may become confused or feel light-headed.

Blood electrolyte analysis may show low sodium (Na) or potassium (K).  However, brain imaging tests like CAT or MRI scans should be normal and an EEG, done to rule out a possible epileptic seizure, should be normal.

Other than possible dehydration, there are no neurologic test findings with abdominal migraine.

5.What is the acute treatment for abdominal migraine?

Dehydration may be treated with Gatorade or oral fluids, or if more severe by IV fluids.

Nausea and vomiting may be treated with:

Benadryl, (diphenhydramine) 25-50mg orally

Phenergan (promethazine) 25 mg orally every 4-6 hours prn

Zofran (ondansetron) odt 4mg orally every 8 hours prn.

 Activity should be bed rest, a quiet dark bedroom, and little stimulation until recovery.

Just like with an attack of migraine, sleep will often treat the attack, with glorious recovery seen after awakening.

 If there is mild headache, this may be treated with Tylenol (acetaminophen) 160 mg, or Advil (ibuprofen) 100 mg.

 Triptans, such as sumatriptan, oral 25 mg, have successfully been used to treat migraine headache accompanying abdominal migraine in older children.  Triptans are the best drugs to treat migraine acutely because they block the release of the inflammatory neuropeptides and stop further migraine development.  Triptans should be used at the onset of the headache, because the neuropeptides are released at 20-40 minutes into an attack.

 6.What is preventive therapy for abdominal migraine?

Cyproheptadine 4 mg orally is an antihistamine that has been used for prevention of migraine in children for a long time.

Elavil (Amitriptyline) oral 10-20 mg at bedtime may help with sleep and decrease the occurrence of attacks of abdominal migraine.

Depakote ER (valproic acid) oral 250-500 mg can reduce frequency of attacks.  It should never be used for menstruating young females who may be sexually active for fear of causing a malformed baby.

Topamax or Trokendia ER (topiramate) 25-75 mg orally may reduce the frequency of attacks.  It should never be used for menstruating young females who may be sexually active for fear of causing a malformed baby.

The betablocker Inderal, or Inderal LA (propranolol) 80mg orally was the first drug approved by the FDA in 1974 for preventive use in adults with migraine and it has been used for abdominal migraine.

 CTRP antibody drugs-Aimovig, Ajovy, and Emgality are given subcutaneously in the abdomen or anterior thigh monthly and have no drug to drug side effects.  Read they can be taken with any drug.  Side effects are low-3% constipation with Aimovig or a mild injection site reaction with all of the drugs which amounts to a small bruise, like one gets from having lab work blood drawn in the antecubital fossa-top side of elbow.

 However, these drugs are not approved for use in persons less than 18 years of age, and although they have had a most favorable impact on adults, cannot be used for children or young teenagers.  Also, there is no current data on the use of these drugs for abdominal migraine.

 7.Learning Cognitive Behavioral Therapy (CBT)

 Cognitive behavioral therapy is a skill that can be learned to help a patient calm his mind and deal with stress, anxious conditions, or trouble sleeping.  The American Psychiatric Association has recommended learning CBT for treating depression, generalized anxiety disorder (GAD), or panic disorder.  This is very appropriate for migraine patients because migraine and depression are 50% comorbid, while migraine and GAD or panic disorder are 40% comorbid.

 The word comorbid means that the two medical conditions, migraine and depression, come together more commonly than by chance.

 Cognitive behavioral therapy is a type of therapy based on analyzing the thoughts we have in our head, which are irrational, and then making rational responses to those thoughts.  We tend to think in terms of sentences which relate to our origins, parenting, and education.  Feelings are thought to be irrational and specific for that individual.  For instance, someone from a foreign country does not have the same pride or memories of America that an American may have with seeing the flag or hearing the Star-Spangled Banner.

 The patient tries to identify the irrational thoughts as they occur and at that moment replace it with a rational response which is less ego deflating and mentally healthier.  This new approach stresses changing a patient’s self-defeating beliefs such as “I must be perfect” and “I must be loved by everyone” by demonstrating their irrationality and rigidity.  Using Cognitive analysis people can understand their errors in light of the core irrational beliefs and then construct a more rational position.

 CBT is likely too much for children, but teenagers can understand it and it has a long history of successful use in migraine patients.  

 CBT is taught in books or by therapists and also by helpful videos on YouTube.  Go to YouTube/CBT and anxiety, or migraine and watch the video.  YouTube is now the world’s greatest educator and over 4 billion people a minute are on it.

CBT.jpg

 8.What are the triggers for abdominal migraine?

 Abdominal migraine has triggers that may produce an attack, just like regular migraine.  The International Classification of Headache Disorders differentiates between a trigger, which may set off a migraine within 24 hours or “aggravating features” like stress or poor sleep which are more chronic life events driving the abdominal migraine attacks.

 Aggravating features:

 Stress

Poor sleep

Too much homework

Too many video games.  Mom, set limits

Sport events.  Soccer, soccer, soccer, football

 Triggers

 Food-nitrates, processed meats like hot dogs or bologna, chocolate, MSG in Chinese food

Missed meals, no breakfast, missed lunch

Heat

Barometric pressure change

Menstruation

 9.Inheritance issues

 Kids whose family members get migraine are more likely to get abdominal migraines.

Of all kids who have chronic stomach pain, up to 15% of them may have abdominal migraines.; Abdominal migraine is rare in adults.

Girls get them more than boys.

 10. Long term Outlook

 Most kids outgrow abdominal migraines within a year or two.

Up to 70% of these children will go on to develop migraine headaches when they grow up.

Some of these kids will also experience abdominal pain in adulthood.

 11.Final statement

Abdominal migraines aren't headaches.

They make your belly ache instead.

Abdominal migraine has similar triggers and aggravating features as adult migraine

And they hurt a lot and cause nausea, cramps, and vomiting.

But you outgrow them.

 

All the best.

 Follow me at:  www.doctormigraine.com, Pinterest, Amazon books, and YouTube.

 Britt Talley Daniel MD