Let me start off by stating that yes – abdominal migraines are a thing. They fit under the umbrella of migraine variants – which are episodic syndromes related to migraines but presenting with symptoms other than headache. Other examples include periodic vomiting, hemiplegic migraine, and retinal/ophthalmic migraine. I won’t cover those three here.

Abdominal migraines are characterized by recurrent bouts of abdominal pain that last from 2 to 72 hours in a child who is asymptomatic in between the episodes. This pain is dull, constant, periumbilical and hard to localize. Children also have at least two of the following; pallor, anorexia, nausea, and/or vomiting. Children are afebrile and do not have peritoneal signs or urinary symptoms. There is no headache, and photophobia and phonophobia ate rarely seen. Some experts think that you should have five discrete episodes before you make a diagnosis.

Up to 1 in 25 children may experience them – with as many as 15% of kids with chronic periodic abdominal pain having abdominal migraines. They present between 2 and 10 years and end by early adolescence – where most transition into experiencing more classic migraine headaches. There is often a very strong family history of migraines as well. Other causes such as constipation or GERD need to be ruled out but a careful history. As you might imagine these children are often worked up for abdominal pain on multiple occasions and the differential is broad including, but not limited to gastritis, GERD, irritable bowel, pancreatitis, cholelithiasis, kidney stones and more. Most of these patients are too young to habitually use marijuana and in my experience cannabis hyperemesis syndrome is not a consideration. If labs have been sent they’ll all be normal – these include the “belly labs,” CBC, Renal/CMP, liver panel, urinalysis, lipase etc,. Imaging is also non-revelatory. formal diagnostic criteria require five episodes. Because symptoms overlap with other conditions that can cause abdominal pain, it is not unusual for children to require some degree of evaluation.

Treatment is symptomatic, and includes ibuprofen, acetaminophen, and ondansetron as first line. Children refractory to these can get the “migraine cocktail” – prochlorperazine + ketorolac OR metoclopramide + ketorolac. In my personal experience this has worked well in the past and parents are receptive too this lines of diagnostic thinking and treatment. many of them have suffered form migraine headaches themselves and are understanding.

References

Angus-Leppan H, Saatci D, Sutcliffe A, Guiloff RJ. Abdominal migraine. BMJ. 2018 Feb 19;360:k179. doi: 10.1136/bmj.k179. Review. PubMed PMID: 29459383.

Klein J, Koch T. Headache in Children. Pediatr Rev. 2020 Apr;41(4):159-171. doi: 10.1542/pir.2017-0012. Review. PubMed PMID: 32238545.

Napthali K, Koloski N, Talley NJ. Abdominal migraine. Cephalalgia. 2016 Sep;36(10):980-6. doi: 10.1177/0333102415617748. Epub 2015 Nov 17. PMID: 26582952.

Winner P. Abdominal Migraine. Semin Pediatr Neurol. 2016 Feb;23(1):11-3. doi: 10.1016/j.spen.2015.09.001. Epub 2015 Oct 21. PMID: 27017015.