Abdominal Migraine

An Under-Diagnosed Cause of Recurrent Abdominal Pain in Children

Laura Carson, MD; Donald Lewis, MD; Marc Tsou, MD; Erin McGuire, MS; Brooke Surran, MD; Crystal Miller, MD; Thuy-Anh Vu, MD

Disclosures

Headache. 2011;51(5):707-712. 

In This Article

Abstract and Introduction

Abstract

Objective.— Our objective was to demonstrate that, despite recognition by both the gastroenterology and headache communities, abdominal migraine (AM) is an under-diagnosed cause of chronic, recurrent, abdominal pain in childhood in the USA.
Background.— Chronic, recurrent abdominal pain occurs in 9–15% of all children and adolescents. After exclusion of anatomic, infectious, inflammatory, or other metabolic causes, "functional abdominal pain" is the most common diagnosis of chronic, idiopathic, abdominal pain in childhood. Functional abdominal pain is typically categorized into one, or a combination of, the following 4 groups: functional dyspepsia, irritable bowel syndrome, AM, or functional abdominal pain syndrome.
International Classification of Headache Disorders—(ICHD-2) defines AM as an idiopathic disorder characterized by attacks of midline, moderate to severe abdominal pain lasting 1–72 hours with vasomotor symptoms, nausea and vomiting, and included AM among the "periodic syndromes of childhood that are precursors for migraine." Rome III Gastroenterology criteria (2006) separately established diagnostic criteria and confirmed AM as a well-defined cause of recurrent abdominal pain.
Methods.— Following institutional review board approval, a retrospective chart review was conducted on patients referred to an academic pediatric gastroenterology practice with the clinical complaint of recurrent abdominal pain. ICHD-2 criteria were applied to identify the subset of children fulfilling criteria for AM. Demographics, diagnostic evaluation, treatment regimen and outcomes were collected.
Results.— From an initial cohort of 600 children (ages 1–21 years; 59% females) with recurrent abdominal pain, 142 (24%) were excluded on the basis of their ultimate diagnosis. Of the 458 patients meeting inclusion criteria, 1824 total patient office visits were reviewed. Three hundred eighty-eight (84.6%) did not meet criteria for AM, 20 (4.4%) met ICHD-2 formal criteria for AM and another 50 (11%) had documentation lacking at least 1 criterion, but were otherwise consistent with AM (probable AM). During the observation period, no children seen in this gastroenterology practice had received a diagnosis of AM.
Conclusion.— Among children with chronic, idiopathic, recurrent abdominal pain, AM represents about 4–15%. Given the spectrum of treatment modalities now available for pediatric migraine, increased awareness of cardinal features of AM by pediatricians and pediatric gastroenterologists may result in improved diagnostic accuracy and early institution of both acute and preventative migraine-specific treatments.

Introduction

Children with chronic recurrent abdominal pain have a high utilization of healthcare resources. As is observed with other chronic pain syndromes, recurrent abdominal pain leads to significant disability, including interference with family, school, and social activities. Accurate diagnosis as to the etiology of the pain is integral to providing explanation and reassurance to the patient and family, as well as maximizing targeted therapeutic options.[1]

Chronic, recurrent abdominal pain occurs in 9–15% of all children and adolescents. The American Academy of Pediatrics Subcommittee on Chronic Abdominal Pain and North American Society of Pediatric Gastroenterology, Hepatology and Nutrition define "functional abdominal pain" as the most common cause of chronic, idiopathic abdominal pain in childhood, after exclusion of anatomic, infectious, inflammatory, or other metabolic causes, and categorize "functional abdominal pain" as 1, or a combination of, 4 clinical entities; functional dyspepsia, irritable bowel syndrome, abdominal migraine (AM), and/or functional abdominal pain syndrome.[1]

First described nearly a century ago, AM occurs in 1% to 4% of children and has received considerable attention as one of many potential etiologies of recurrent abdominal pain in children.[2,3] In 2004, the International Headache Society (ICHD-2) included AM among its "periodic syndrome of childhood that are precursors for migraine" (Table 1).[4,5] In 2006, Rome III Gastroenterology established separate, but similar, criteria for AM, confirming AM as a well-defined cause of recurrent abdominal pain (Table 2).[6]

International Classification of Headache Disorders—2nd Version defined AM as an idiopathic disorder characterized by attacks of midline, moderate to severe abdominal pain lasting 1–72 hours with vasomotor symptoms, nausea, and vomiting. A key feature of AM is the complete resolution of symptoms between attacks. The pain is of moderate to severe intensity. In 2001, Dignan et al introduced a comprehensive guideline which included valuable exclusionary criteria for patients with the following features: mild symptoms not interfering with daily activities, burning pain, non-midline abdominal pain, symptoms consistent with food allergy or other gastrointestinal disease, attacks less than 1 hours, or persistence of symptoms between attacks.[7]

Abdominal migraine is more common in those with a family history of migraine headaches and emerges between the ages of 3 and 10 years.[8] While AMs rarely persist into adulthood, evidence suggests an evolution of AM into migraine headaches, ergo a "precursor for migraine."[7] In a 10-year prospective study of nearly 150 children referred for recurrent abdominal pain, Bentley et al identified 70 children whose symptoms were consistent with AM.[9] An equal number of males and females were affected by this condition, and 90% had a positive family history of migraines in a first-degree relative. Consistent with other reports, diagnosis was made between the ages of 6 and 10 years.[8–10]

One of the curious issues regarding the entity of AM is the apparent trans-Atlantic dissociation. The overwhelming body of literature pertaining to AM arises from Europe, primarily Scotland, with very little coming from US centers. Is the diagnosis made more commonly in Europe and uncommonly in the USA? Is there inadequate awareness among US clinicians about AM? Russell et al proposed that the limited recognition of AM among clinicians can be explained, in part, by referral patterns and biases. Children with recurrent abdominal pain are typically referred to gastroenterologists, where organic causes are explored and migraine is rarely considered.[11] Do gastroenterology services in the USA consider AM among the potential causes of unexplained abdominal pain? We hypothesize that despite the recognition of AM by the gastroenterology and headache communities, AM is likely being under-diagnosed in the USA.

The purpose of this study was to assess the population of children within a single academic pediatric gastroenterology clinic who present with "recurrent abdominal pain" to ascertain whether there is an unrecognized subset of patients who fulfill the diagnostic criteria for AM.

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