However, in Europe, the diagnosis of abdominal migraine is much more prevalent, because in the US it is often misdiagnosed. The healthcare system in Europe seems to have a much better grasp of the condition while US doctors are still struggling to understand it. A 2009 study found that it is likely that as many as 15% of pediatric gastrointestinal patients who present with abdominal pain that is idiopathic and recurrent likely have abdominal migraine.
As the name suggests, abdominal migraines are not what most people think of when they hear migraines – they aren’t headaches. Instead, they cause pain in the stomach and often include intense pain cramps, nausea, and vomiting.
They tend to share the same triggers as migraine headaches and often occur in families where members are prone to migraines. What’s more, children who have abdominal migraines usually get the headache version as well or they develop as the child matures. The link between abdominal migraines and the migraines that produce headaches is still a bit of a mystery for doctors.
Axon Optics talked to Dr. Brett Caminez, DC, CCEP of Caminez Chiropractic in Orangeburg, New York. Dr. Caminez specializes in headache and migraine treatments as well as postural correction methods which utilize chiropractic care in conjunction with stretching and exercise programs. He is one of only a handful of New York chiropractors who are a Certified Chiropractic Extremities Practitioner (CCEP) and has been in private practice in Orangeburg NY for more than 14 years.
“The link between abdominal migraines and migraine headaches is very poorly understood,” says Dr. Caminez. “In fact, since abdominal symptoms can have so any causes, especially in children, many doctors are only able to make an accurate diagnosis years after the abdominal migraines when the child becomes a teen and then develops classic migraines. We still do not understand why children who have abdominal migraines often grow up and experience migraine headaches, only that they do and that there is a hereditary nature to them.”
Signs and Symptoms of Abdominal Migraine
The symptoms of abdominal migraines are distinctive; the most prevalent being midline abdominal pain. This means that the pain is in the middle of the abdomen, around the belly button. The pain does not extend to the sides.
Axon Optics published the Guide to Types of Headaches in 2016. In it, abdominal migraines are characterized as:
A migraine that does not affect the head, but rather the abdomen and can last from a few hours up to 72 hours. During attacks at least two of the following are symptoms: anorexia, nausea, vomiting, paleness. This is mostly commonly found in children and symptoms do not remain between attacks. Many children who suffer from abdominal migraine have migraine later in life.
The symptoms are what define this unusual condition and also include:
- Severe abdominal pain or intense soreness in the stomach (the pain is so intense that it interferes with the patient’s normal activities)
- Pain that causes
- Intense nausea or queasiness
- Vomiting
- Unable to eat or loss of appetite (anorexia)
- Flushed or pale
- Very low energy or listless
- Headache
- Very drowsy
- Photophobia (sensitivity to light)
- Sensitivity to sound
- Frequent yawning
- Dark circles under the eyes
- Fever (somewhat rare)
The onset of the attack is usually sudden and the symptoms or attack itself usually very severe. An abdominal migraine can occur with no aura or warning at all. An attack can last anywhere from 1 hour to 72 hours, but usually it lasts 4 or more hours. Patients do not experience any symptoms between their attacks.
The pain of the attacks is intense. Abdominal migraines predominantly occur in children and the symptoms may render the child non-functional. They may scream and cry in pain to the point that their parents take them to the emergency room.
The child will also appear extremely pale, almost ghostly and this can alarm parents as well as doctors. This can lead to misdiagnoses including surgery because the child looks so ill and is in so much pain. The truth is, though, that abdominal migraines do not pose any greater danger or risk that headache producing migraines. They are just as uncomfortable though and can be just as debilitating.
Causes of Abdominal Migraine
Doctors have not established an exact cause of abdominal migraines. There is some speculation that the condition comes from an issue with the brain-gut pathway. Specifically, cell activity along these pathways that is abnormal, triggering changes to the blood vessels in the head and pain.
A small study published in February 2016, discovered a link between this type of migraine and how digested food moves through the child’s intestines. In the abdominal migraine patients, this process is slower than normal. Changes in the levels of histamine and serotonin in the body can also bring about endocrinologic changes that can trigger an attack.
Abdominal migraines are essentially migraines that occur in the stomach instead of the head, but they seem to have many of the same triggers that headache inducing migraines do. The condition seems to be hereditary, so children who have a parent with migraines may be more likely to have abdominal migraines.
A study published in the Journal of Pediatric Gastroenterology and Nutrition found that the majority of children with the condition (more than 90%) had a family member (sibling or parent) who had migraines. It should also be noted that the condition is more prevalent in girls than in boys.
Some of the more common triggers of abdominal migraines include:
- Chemicals such as nitrites that are found in processed foods such as deli or processed meats, lunch meat, packaged sandwich ham, turkey, and chicken
- Chocolate
- Caffeine
- Bright lights
- Foods that contain monosodium glutamate (MSG) including Chinese food, dressings, seasonings, condiments, and many buffet foods in restaurants
- Motion sickness
- Flickering lights
- Being worried
- Swallowing a lot of air
- Stress
- Lack of sleep
- Being upset
- Fatigue or exhaustion
Learning to identify what triggers abdominal migraines is an important step in preventing them. In many cases, taking proactive steps to prevent the attacks can lead to fewer attacks or a decrease in intensity of attacks.
Diagnosing Abdominal Migraine
Abdominal migraine is usually a diagnosis of exclusion, meaning that the doctor uses a process of elimination to reach that conclusion. The doctor may order several tests including an endoscopy or ultrasound to ensure that there are no other causes for the pain. A complete medical history is also vital in order to identify certain risk factors. Often doctors will suspect serious medical conditions like appendicitis, so these must be ruled out.
The pattern of the attacks is also taken into consideration. Abdominal migraines tend to follow a set attack pattern, meaning that they may occur with the same symptoms or at the same time of day. They may always last the same amount of time.
While they do come on suddenly, these patterns need to be noted as they will aid the doctor in making his or her diagnosis. Parents should record all the details of an attack: duration, symptoms, foods eaten prior to attack, time of day, noted stress or worry, and other factors. They should document this information for at least five attacks and show any activity between episodes (usually there are no symptoms between the attacks) then present it to the child’s doctor.
According to Dr. Caminez, the diagnosis is usually not straightforward. “The signs will be confusing at best,” he says. “Most doctors usually fall back on the abdominal migraine diagnosis only after all other gastrointestinal, blood work and other diagnostic tests are negative.”
When assessing a patient for diagnosis of abdominal migraine, the doctor looks for the patient to meet very specific criteria. They must have had a minimum of five attacks where they experienced abdominal pain as well as certain accompanying symptoms. The pain must be located in the periumbilical or midline region of the abdomen or be poorly localized. It must either feel sore or be a dull ache. It must also be at least moderate in intensity, or may be severe. While some patients will exhibit all of these pain characteristics, a diagnosis can be made if one two of the three are observed. During the course of the attack, the patient must also exhibit at least two of these symptoms: nausea, pallor, vomiting, and anorexia.
Other traits of abdominal migraine that should be observed include the length of the attack which is between 2 and 72 hours with no symptoms at all between the attacks. Of course, other disorders must be ruled out before a diagnosis of abdominal migraine can be made.
The patients of this condition are predominantly children which can make an accurate diagnosis very difficult. Younger children may have trouble verbalizing their discomfort and may not be able to describe the symptoms they are experiencing. They may not be able to tell the difference between being nauseated and being unable to eat or losing their appetite. It is up to parents to observe their children and identify certain signs such as the severity of the pain. It is interfering with the child’s daily activities, that is significant.
Treatment for Abdominal Migraine
Treatment for abdominal migraine often focuses on prevention rather than abortive methods. There are medications that are effective for some patients, but doctors are usually hesitant to prescribe them to children unless the attacks are frequent, or the symptoms are very severe.
One of the major problems is that, while typical migraine medications may work, many are not approved for children. This is the case with two popular triptans, Maxalt (rizatriptan) and Imitrex (sumatriptan). The medications are not approved for children, but some older children may be able to use sumatriptan delivered as a nasal spray.
Other medications for abdominal migraines include:
- Periactin (cyproheptadine) is an antihistamine that also helps calm stomach problems
- Inderal (propranolol) is a beta blocker used to treat heart conditions but is also effective for migraines
- Sandomigran (pizotifen) is benzocycloheptene-based drug that is often used to treat migraine headaches
- Depakote or Depakene (valproic acid) is used to treat seizures as well as bipolar disorder and can help stop abdominal migraine attacks
“Unfortunately, most treatments for abdominal migraines are pharmacological in nature,” Dr. Caminez says. “Anti-seizure, anti-inflammatory or even anti-depressants are common treatments and, in many cases do help, but fail to address the underlying condition which caused the problem in the first place.”
Medications that may be prescribed to children include amitriptyline (Vanatrip, Elavil, or Endep), topiramate (Topamax), and cyproheptadine (Periactin). However, there are warnings issued by the FDA that some of these drugs show an increased risk of thoughts of suicide in teens and children, particularly amitriptyline and similar antidepressants. Because of this, some of the medications are not recommended for young patients under 12. Propranolol has had good results.
Prevention can be very effective. Parents and doctors can team up to help the children determine what is triggering the attacks. A migraine diary is a very good start. Make notation about the day, date, and time that the attack occurred, what foods the child has eater that day and even the previous day (it can take up to 72 hours for some foods that trigger migraines, allergies, and food sensitivities to completely leave your system), their activities prior to the attack, any medication they have recently taken, and if there are any stressors in their file or causes for worry. Identifying these triggers and eliminating them can help prevent attacks.
Dr. Caminez also has this advice for parents of children with abdominal migraine. “I am not aware of any new significant treatments at this time, but what does help though, as with migraines in adults, is understanding lifestyle, which plays a significant role.”
“If you suspect your child has abdominal migraines, look for patterns.” he says. “Do they tend to happen at a certain time of the day, what are the eating habits even days before the migraine? Has your child been properly hydrating, exercising, sleeping? As a Chiropractor, I am focused on the physical aspects of a person’s body. I have seen a rise in headaches in children with all of the screen time and texting they are exposed to, which can be easily changed. Similar to migraines in adults, abdominal migraines have many causes, but sometimes simple changes can make a big difference.”
Children who have abdominal migraines should have good health practices such as regular exercise, a nutritious diet that includes lots of fiber, and good hydration. They also need to get plenty of sleep and learn how to handle stress as well as how to deal with their emotions and manage problems. When an attack occurs, one of the best treatments that many doctors recommend is sleep.
Treatment for abdominal migraines depends on the patient and how the condition affects them specifically. Often, if the child can just sleep off the attack, they will feel better. Allowing them to lie down in a cool, dark, quiet room can help a lot. Acetaminophen or ibuprofen can also ease some of the discomfort as can nausea medication. Other natural treatments that have been shown to be very effective in treating abdominal migraines are chiropractic and acupuncture as well as counseling and cognitive behavioral therapy. Also, limiting a child’s time on their computer, mobile device, and television can also help.
What Parents Need to Know about Abdominal Migraine
One of the biggest concerns of parents who have children with abdominal migraines is the severe pain that the condition inflicts during an attack. Sometimes they are hesitant to take the child to the doctor, thinking that it is a “stomach flu” or “just a little stomach bug.” However, if your child is experiencing severe abdominal pain, especially if it happens more than once, they should see a doctor to rule out other, more serious problems.
Many parents are often concerned that even though the pain comes and goes, during an attack it is so severe that is often interferes with the child’s daily activities which includes school. Several abdominal migraine episodes during one school year could result in the child missing a lot of school.
For parents who suspect their children may have abdominal migraines, Dr. Caminez has this advice, “I recommend they always start with the child’s pediatrician who can then be a referral source to a headache specialist. I find that abdominal migraines, like migraines in adults can be very confusing to diagnose.” He continues, “I have seen children as well as adults with migraines dismissed by doctors who just feel the condition is ‘in their head.’ I always remind parents and patients that their doctor is there to give their expert opinion and treatment but if the parent is not satisfied with the care, it is never a bad idea to get a second opinion.”
While there is no cure for abdominal migraines, many children do outgrow them by the time they reach adolescence. The condition does not usually pose any more of a risk for complication than migraines that cause headaches do, but it can be unsettling to see your child in such pain. It can also be very troubling to watch the numerous tests and difficulty with a diagnosis as the doctors try to find out what is going on. The more information you can provide your child’s doctor regarding their symptoms, the sooner they can start finding treatment that works. This is why a migraine diary is so important.
Talking to Your Child’s Doctor about Abdominal Migraine
If your child is experiencing symptoms that you feel may be abdominal headaches, the more you can tell their doctor, the better. Show them the migraine diary that you have been keeping for your child and tell them about any symptoms that really concern you.
Abdominal migraine is an unusual condition and many doctors are not well acquainted with the symptoms, diagnostic criteria, or treatment. A migraine specialist may be a better option for diagnosing and treating your child. These doctors specialize in migraines and may be better equipped to provide a diagnosis. They can then work with you to create a treatment plan for your child that will help prevent attacks and relieve symptoms in the event an attack occurs.
However, talking to a specialist or your child’s pediatrician can be a daunting task. Having an open, honest conversation and sharing as much information as possible give the doctor insight into certain lifestyle triggers and any familial traits that can be causing the attacks. Often, though, the diagnosis starts at home. It begins with parents observing their child’s behavior and noting their illness. From there it leads to the doctor’s office and testing. Still, the parents are the key. Dr. Caminez offers some signs parents can look for.
“If there is a family history of migraines or headaches that should be a sign not to overlook,” he says. “It is certainly the standard of care to rule everything else out and since there is not test or blood work that can give a definitive answer, for now it will have to be a diagnosis of exclusion.”
Bring along a pen and paper when you go to your child’s appointment so you can jot down any information or notes on what the doctor says. Make sure to write down any advice on diet, sleep, exercise, and stress factors so that you can address them later. If your child is given a special diet, make sure you follow it to the letter. Your children depend on you. It is up to you to be their advocate, their nurse, and everything in between. You can make a difference and help your child escape the painful prison of abdominal migraines.
Resources for Abdominal Migraine Patients and their Families
Although abdominal migraines are rare, there are several very good resources for patients and their families. Facebook has two very good groups and some parenting and health forums have good threads that discuss the condition.
- Mumsnet Forum
- Kids with Abdominal Migraines or Regular Migraines – Facebook
- Essential Kids Forum – Abdominal Migraines
- GardenWeb Forum
- Abdominal Migraines Support Group – Facebook
- Essential Kids Forum – Stomach Migraine
- Patients Like Me
Sometimes it helps just to know that you are not alone in a situation. Sometimes it helps to hear from someone who has been where you are, who has gone through what you are experiencing. Look for support groups in your area as well as online. You don’t have to go through it alone and you shouldn’t have to.
Resources
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“Abdominal Migraine and Cyclic Vomiting Syndrome.” Abdominal Migraine and Cyclic Vomiting Syndrome | Pediatrics Clerkship | The University of Chicago, pedclerk.bsd.uchicago.edu/page/abdominal-migraine-and-cyclic-vomiting-syndrome.
“Abdominal Migraine: Prophylactic Treatment and Follow-up : Journal of Pediatric Gastroenterology and Nutrition.” LWW, journals.lww.com/jpgn/Fulltext/1999/01000/Abdominal_Migraine__Prophylactic_Treatment_and.10.aspx.
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Devanarayana, Niranga Manjuri, et al. “Abdominal Migraine in Children: Association between Gastric Motility Parameters and Clinical Characteristics.” BMC Gastroenterology, BioMed Central, 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC4770524/.
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