US Clinicians Underrecognize Abdominal Migraine in Children

Daniel M. Keller, PhD

September 14, 2009

September 14, 2009 (Philadelphia, Pennsylvania) — Abdominal migraine may represent up to 15% of pediatric gastrointestinal patients who experience idiopathic recurrent abdominal pain, if results presented here at the 14th International Headache Congress are representative.

Although the condition is well recognized in Europe, it is underdiagnosed in the United States, according to investigator Donald Lewis, MD, professor and chairman of the Department of Pediatrics at Eastern Virginia Medical School and senior vice president for academic affairs at Children's Hospital of the King's Daughters in Norfolk, Virginia.

Children with recurrent abdominal pain use significant amounts of healthcare resources, he said, and the condition can lead to dysfunction and disability that may interfere with school, family, and social activities.

Dr. Lewis told Medscape Neurology that abdominal migraine is classified as one of the period syndromes of childhood that are precursors to migraine. "If you track those kids [for] long through adolescence, most of them grow up to have migraine," he said.

Belly Pain a Cardinal Feature

Dr. Lewis, a pediatric neurologist, explained that abdominal migraine is characterized by episodes of moderate to severe midline, periumbilical, or poorly localized pain lasting for 1 to 72 hours with nausea, anorexia, pallor, and occasionally headache. "But headache is not one of the cardinal features. It's episodes of belly pain," he emphasized. The condition was included in the 2004 International Classification of Headache Disorders and recognized by the 2006 Rome III criteria for functional gastrointestinal disorders as a well-defined type of recurrent abdominal pain.

Through chart reviews, Dr. Lewis and colleagues assessed patients with recurrent abdominal pain in the hospital's pediatric gastroenterology clinic to define the proportion of patients who might fulfill the International Classification of Headache Disorders 2004 criteria for abdominal migraine. Eligible subjects were girls (41%) or boys (59%) who were 1 to 21 years old and who did not have a known diagnosis of causes of chronic abdominal pain. Of an initial cohort of 600 children, 458 met the inclusion criteria. Twenty children (4.4%) met the International Classification of Headache Disorders 2004 diagnostic criteria, with an additional 11% having probable abdominal migraine (documentation lacking for ≥1 diagnostic criterion).

"So we have this large subset of children who are languishing with a vague diagnosis in [gastrointestinal] clinics who most likely have abdominal migraine," Dr. Lewis said. Making the correct diagnosis of abdominal migraine means the spectrum of migraine medications will become available to these children, he added.

Migraine prophylactic medications and acute treatments for migraine attacks are available and efficacious for abdominal migraine. Because the study was solely demographic, it did not test medication efficacy, but Dr. Lewis said the European literature has documented the efficacy of these treatments.

He speculated that abdominal migraine is underrecognized in the United States because physicians have not been taught about it. The message about the existence of the condition is especially relevant to pediatric gastroenterologists and general pediatricians. Dr. Lewis suggested that pediatricians might better refer such patients to pediatric neurologists instead of to gastroenterologists. Informed families, too, may alert their physicians if their child has recurring symptoms consistent with a diagnosis of abdominal migraine, especially if a parent, particularly the mother, has a migraine condition, as migraine is often inherited.

Background of Episodic Abdominal Pain

Brian McGeeney, MD, MPH, assistant professor of neurology at Boston University, Massachusetts, who was not involved in the study, told Medscape Neurology that in his clinical experience with adults, abdominal migraine is a real entity. "They seem to have a background of episodic abdominal pain in childhood more than one would expect by chance," he said.

"Posters like this should really heighten the awareness of this unusual syndrome to adult neurologists as well as pediatricians." Knowing a patient's childhood history of abdominal symptoms may be one more clue in the diagnosis of adult migraine.

Although abdominal migraine may be a precursor to and temporally linked with later migraine, for Dr. McGeeney, a strong indication that abdominal migraine is really a form of migraine is that it often responds to a broad range of migraine prophylactic medications.

The study was supported through the Chairman's Fund of the Department of Pediatrics with no industry association. Dr. Lewis has disclosed no relevant financial relationships. Dr. McGeeney has done consulting work for Merck, GlaxoSmithKline, and Lilly.

14th International Headache Congress: Abstract PO222. Presented Saturday, September 12, 2009.

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