Abdominal migraine is a paroxysmal idiopathic disorder characterized by episodes of pain in the central part of the abdomen lasting 1-72 hours. A painful attack is accompanied by dyspeptic, vasomotor phenomena. Abdominal migraine is diagnosed on the basis of clinical symptoms after excluding possible causal pathology from the gastrointestinal tract, kidneys, and brain. Treatment involves measures aimed at relieving abdominal pain (NSAIDs, combined analgesics, triptans, antiemetics), and therapy in the interparoxysmal period (preventive medication, compliance with the regime, exclusion of triggers).
43.8 Other migraines
The term “abdominal migraine” (AM) has been used in neurology since 1921. Since this pathology occurs mainly in children and adolescents, it was previously attributed to periodic childhood syndromes. Later it turned out that similar conditions can be found in adult patients. According to the 2013 International Headache Classification, abdominal migraine refers to “Episodic syndromes that can be combined with migraine.”
According to various data, abdominal migraine is observed in 2-4% of children. In most cases, the onset of the disease occurs at the age of 2-10 years, the peak of clinical manifestations – at 10-12 years. The ratio of sick girls and boys under 20 years of age is 3:2, at an older age, women get sick 2 times more often than men. 70% of children with AM later have attacks of classic migraine cephalgia.
Reasons of abdominal migraine
The exact causes have not been established, a multifactorial etiology is assumed. Numerous observations of patients with AM have shown the important role of psychological aspects: the characteristics of the character of the child and parents, the relationships that have developed in the family. Restless, excitable children with hypersensitivity to pain and discomfort are prone to the disease. The situation is aggravated by the unstable psyche of parents (especially mothers) – in families of children with AM, the risk of maternal neuroses is high.
65% of the patients have parents suffering from migraine, which indicates the presence of a hereditary tendency. Summarizing the data obtained, many researchers believe that abdominal migraine occurs when exposed to psychological factors against the background of a genetically determined predisposition. Triggers provoking migraine paroxysm are:
- Psychoemotional and physical overload. Strong negative or positive emotions, psychological stress during a speech, passing an exam, etc. Weather sensitivity is possible. An attack can also be caused by sleep deprivation, physical fatigue.
- The use of certain foods. In a number of patients, paroxysms are associated with the use of fatty varieties of fish, chocolate, nuts, the exclusion of which leads to a decrease in the frequency of episodes of abdominal pain.
The mechanism of occurrence of AM has not been established, there is no morphological substrate of the disease. The disorders are of a functional nature, associated with the existence of direct interactions between the central nervous system and the gastrointestinal tract, due to their development from the same embryonic tissues. One of the main pathogenetic hypotheses suggests the following mechanism of development of abdominal paroxysm: stress increases the activation of the central nervous system, there is an increased release of neuropeptides and neurotransmitters, resulting in nervous, vegetative, vascular dysregulation of the gastrointestinal tract.
According to the researchers, a violation of adequate regulation leads to hypersensitivity of intestinal receptors, due to which the usual stretching of the intestine provokes hyperimpulsation into the spinal cord and further along the ascending pathways into the cerebral structures. The subsequent occurrence of paroxysms is due to the preservation of trace memory with the fixation of the pathological mechanism of the appearance of pain at the level of the brain.
Symptoms of abdominal migraine
Migraine is characterized by transient paroxysms of abdominal pain, interspersed with asymptomatic intervals lasting several weeks or months. Abdominal pain of moderate or severe intensity is localized in the umbilical region, in 16% of cases it has a diffuse character. Abdominal pain is characterized by most patients as dull.
Pain syndrome occurs with anorexia, nausea, vomiting, diarrhea. Pain adversely affects the child’s ability to lead a normal life. The behavior of the patient depends on the age: younger children are capricious, ask for their hands, older ones prefer to lie down, cannot attend school. Vasomotor reactions are typical: pallor of the skin (in 5% of cases — hyperemia), cold extremities.
In 75% of cases, abdominal migraine is noted in the morning. Sometimes its appearance is preceded by prodromal phenomena in the form of anorexia, changes in behavior or mood. The duration of the attack varies from 1 hour to 3 days, the average is 17 hours. The disappearance of pain during sleep is characteristic. The frequency of paroxysms during the year ranges from 2 to 200.
In most patients, abdominal migraine is observed monthly, the average annual number of attacks is 14. Over time, the number of cephalgic migraine paroxysms that occur between attacks of abdominal form or simultaneously with it increases.
Abdominal migraine with a high frequency of seizures makes it difficult for a preschool child to visit children’s groups, causes skipping lessons for schoolchildren. Pain syndrome negatively affects the child’s psyche, is dangerous by the formation of asthenia, neurasthenia, depressive, hypochondriacal qualities of character.
Serious complications can be caused by erroneous primary diagnosis of AM as an intestinal infection, acute abdomen. Inadequate antibiotic therapy provokes the development of intestinal dysbiosis. Surgery for overdiagnosed acute abdominal pathology entails a long recovery period, may have a number of surgical complications.
Diagnostic difficulties are associated with the non-specificity of symptoms, its similarity to the manifestations of a number of gastrointestinal diseases, poor awareness of pediatricians about the existence of an abdominal variant of migraine. During the initial treatment during the diagnosis, it is necessary to confirm the exclusively functional nature of the pain syndrome, which requires a thorough examination for the presence of anatomical, neoplastic, inflammatory disorders of the gastrointestinal tract. The list of recommended studies includes:
- General inspection. It is performed by a pediatrician, gastroenterologist. The absence of signs of gastrointestinal tract damage is characteristic. The tongue is clean, palpation of the epigastrium is painless, there are no symptoms of irritation of the peritoneum, the intestines are not spasmed. During the period of paroxysm, palpation of the abdomen is difficult due to hyperesthesia.
- Laboratory diagnostics. The general analysis of blood, urine, coprogram correspond to the norm, do not display inflammatory changes. Biochemical blood analysis without pathological changes. The normal level of pancreatic enzymes (amylase, lipase) makes it possible to exclude the pathology of the pancreas. Bacteriological sowing of feces does not allow the growth of pathogenic microflora.
- Ultrasound of the abdominal cavity and kidneys. Sonography is necessary to assess the anatomical structure of organs, to identify organic pathology. It is of great importance when performing difdiagnostics. If necessary, ultrasound of the kidneys can be supplemented with excretory urography.
- Radiography of the intestine. It is carried out with contrast. It does not confirm anomalies of development, changes in the configuration and relief of the mucosa. Helps to eliminate neoplasms, intussusception, intestinal obstruction, Crohn’s disease.
- Dopplerography of the abdominal aorta. Typical for most patients is an increase in the rate of linear blood flow in the abdominal aorta. The changes are especially pronounced during the examination during paroxysm.
- MRI of the brain. Tomography is indicated in the presence of cephalgia. The study is necessary to exclude intracranial pathology: brain tumors, hydrocephalus, cerebral cyst, intracranial hematoma.
The diagnosis is made if the symptoms correspond to the Roman diagnostic criteria and there is no other causal pathology. Fundamental is the presence in the anamnesis of at least five similar episodes of blunt umbilical or diffuse abdominalgia lasting 1-72 hours, accompanied by at least two of the listed symptoms: nausea, vomiting, pallor, anorexia. Differential diagnosis is carried out with intestinal infections (dysentery, food poisoning, salmonellosis), enteropathy, acute abdomen, irritable bowel syndrome, functional dyspepsia, pancreatitis, kidney diseases.
Treatment of abdominal migraine
The principles of therapy correspond to the treatment of simple migraine. Therapeutic measures should be carried out in a comprehensive manner, including relief of paroxysms of abdominalgia and intercalative treatment. Patients are supervised by a neurologist, a neurologist-algologist. The main therapeutic stages are:
- Therapy of paroxysm. Conventional analgesics are ineffective. Nonsteroidal anti-inflammatory drugs (ibuprofen), combined codeine-containing pharmaceuticals, paracetamol are used. Drugs from the group of triptans (sumatriptan, eletriptan) are effective, but their use in pediatric practice is limited. Repeated vomiting is an indication for the appointment of antiemetic drugs. Some authors point to the possibility of arresting an attack in children with intravenous administration of valproic acid.
- Preventive treatment. It is necessary to identify trigger factors, an explanatory conversation with the child and his parents about the mechanisms of the onset of seizures, the elimination of provoking influences. General recommendations are the observance of sleep and rest, restriction of psychological and physical exertion, normalization of nutrition, exclusion of provocative products. AM with a high frequency of seizures requires preventive pharmacotherapy. It is possible to use the following drugs: ciproheptadine, pisotifen, propranolol, sedatives.
Prognosis and prevention
There are no exact prognostic data. Predominantly benign course is characteristic. Some studies indicate the disappearance of the abdominalgia after adulthood. In 70% of children’s patients, regardless of the presence of migraine headache episodes, abdominal migraine eventually transforms into a classic cephalgic form. The prevention of AM is facilitated by a friendly, trusting psychological atmosphere in the family, compliance with the daily routine and nutrition, an adequate psycho-emotional load of the child corresponding to the peculiarities of his nervous system.