Case Studies in Headache Archive - #171 - November/December 2009
Abdominal Migraine
By Christina Peterson, MD
Medical director, Oregon Headache Clinic, Clackamas, OR
THE CASE
Cassie is a 20-year-old woman who has had episodes of unexplained abdominal pain since she was nine. As a child, she was evaluated by a pediatric gastroenterologist. No abnormalities were found in the stomach or intestines to explain her abdominal pain, and she was referred to a psychologist for treatment of “stress.” At age 14, Cassie’s abdominal pain episodes became somewhat more frequent. They often seemed to occur near the time of her menstrual cycles. Now, as a young adult, Cassie has begun to notice that her episodes are preceded by a warning of fatigue and are accompanied by one-sided headaches with nausea and sensitivity to light.
DISCUSSION
Abdominal migraine occurs primarily in children, starting at an average age of seven. About 24% of children with abdominal migraine also have migraine headaches and a family history of migraine is common. For many children, the abdominal symptoms resolve over time and then migraine headaches begin to occur, sometimes later in life. This has led to the conclusion that abdominal migraine may represent a migraine variant.
While it is uncommon for abdominal migraine symptoms to persist into adulthood, it does occur, as happened with Cassie.
The symptoms of abdominal migraine most commonly involve a dull pain in the mid-abdominal region, which can last from one to 72 hours. Sometimes the pain is hard to describe, and is explained as, “It just hurts.” The episodic pain can be accompanied by loss of appetite, or by nausea and vomiting. There can also be pallor (or, on occasion, flushing), fatigue and drowsiness.
It can be difficult to figure out what is wrong, and it is usually necessary to make certain that there is no problem in the gastrointestinal tract. Diagnosis may include x-ray studies of the upper gastrointestinal tract or other tests. Since irritable bowel syndrome (IBS) is also more common in migraine sufferers, and can be a cause of abdominal pain and cramping, sometimes a trial of a high-fiber diet will be recommended to see which condition is responsible for the abdominal pain. If the high-fiber diet relieves the symptoms, IBS is likely the cause.
Most of the literature about medications for abdominal migraine has looked at the pediatric population, and most recommendations for adults have been extrapolated from this. In both adult and pediatric populations, abdominal migraine has been shown to respond to migraine-specific medications. Case reports also indicate that acute attacks may respond to intravenous valproic acid, a form of treatment sometimes used for acute migraine headache attacks. Taking a daily medication to prevent attacks is also possible—studies thus far have shown some positive results with propanolol, cyproheptadine (used mostly in children), and pizotifen (not available in the US).
CASE CONCLUSION
Cassie decided to do a new gastroenterological evaluation. Because she has a cousin with celiac disease, she wanted to make certain that gluten intolerance was not the cause of her abdominal pain. None of the tests revealed any abnormalities. She tried a high-fiber diet and then a gluten-free diet for a few months. Her symptoms continued unchanged.
The lack of a gastrointestinal cause for Cassie’s symptoms confirmed a diagnosis of abdominal migraine. She has been able to take propanolol, which reduces the frequency of the attacks, and has been given a triptan for treatment of acute attacks. This helps her to manage both the headaches and the abdominal pain.
