Recognizing and Diagnosing Abdominal Migraines

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1 ARTICLE Recognizing an Diagnosing Abominal Migraines Debbie M. Popovich, MSN, CPNP, Denise M. Schentrup, DNP, ARNP-BC, & Allison L. McAlhany, MSN, CPNP ABSTRACT Abominal migraine affects 1% to 4% of chilren an is a variant of migraine heaaches. Onset is seen most often between the ages of 7 to 12 years, with girls affecte more often than boys. Presenting symptoms inclue acute incapacitating non-colicky periumbilical abominal pain that lasts for 1 or more hours. Pallor, anorexia, nausea, vomiting, photophobia, or heaache may be associate with the episoes, an a family history of migraine heaaches often is note. The iagnostic process begins with a thorough history an physical examination an often follows a series of exclusions or elimination of other organic causes. Limite research exists regaring treatment options, but they may inclue pharmacologic intervention an prevention base on lifestyle moifications. J Peiatr Health Care. (2010) 24, KEY WORDS Abominal migraine, migraine, abominal pain, heaache, periumbilical pain, cyclic vomiting synrome Abominal migraine (AM) affects as many as 1% to 4% of all chilren in the Unite States (Collins & Debbie M. Popovich, Assistant Professor, University of Floria College of Nursing, Gainesville, FL. Denise M. Schentrup, Clinical Assistant Professor, University of Floria College of Nursing, Gainesville, FL. Allison L. McAlhany, Clinical Assistant Professor, University of Floria College of Nursing, Gainesville, FL. Conflicts of interest: None to report. Corresponence: Debbie M. Popovich, MSN, CPNP, University of Floria College of Nursing, PO Box , Gainesville, FL 32610; [email protected] /$36.00 Copyright Q 2010 by the National Association of Peiatric Nurse Practitioners. Publishe by Elsevier Inc. All rights reserve. oi: /j.pehc AM is characterize by acute, paroxysmal episoes of abominal pain followe by intense periumbilical pain. Thomas, 2007; Rasquin et al., 2006). However, it often is overlooke as chilren are teste by any number of specialists for a multitue of organic conitions before the correct iagnosis is mae. To some extent, the inability of many chilren to aequately escribe their pain experience may hiner efforts at iagnosis, an migraine experts, usually neurologists, o not often see chilren presenting with AMs (Russell, Abu-Arafeh, & Symon, 2002). Nurse practitioners an peiatricians are more familiar with this synrome but may lack knowlege about recently publishe criteria to ai in iagnosing it. Diagnostic criteria for AM was ae to the International Heaache Society s International Classification of Heaache Disorers-II (ICHD-II) as recently as 2004 (Box 1) an to the Rome III Peiatric Criteria for Functional Gastrointestinal Disorers (FGIDs) in 2006 (Box 2) (Rasquin et al., 2006). The two criteria iffer in the number of episoes require for iagnosis. The Rome III criteria suggest the iagnosis after two episoes, whereas the ICHD-II requires five episoes for a iagnosis of AM. Fortunately, useofeitherofthese criteria to ai in iagnosis may consierably shorten what has been a typically protracte evaluation process. In simplest terms, AM is characterize by acute, paroxysmal episoes of abominal pain followe by intense periumbilical pain. Typically there is no accompanying heaache with the abominal symptoms. The conition is more prevalent in girls than in boys (3:2). The mean age of onset is 7 years, with a peak at 10 to 12 years of age for both sexes (Rasquin et al., 2006). Occasionally, it may persist into aulthoo, although this is quite uncommon. Dignan an colleagues (2001) 372 Volume 24 Number 6 Journal of Peiatric Health Care

2 BOX 1. Diagnostic criteria for abominal migraine as establishe by the International Heaache Society an reporte by the International Classification of Heaache Disorers II, 2004 Definition An iiopathic recurrent isorer occurring primarily in chilren an characterize by episoic miline abominal pain manifesting in attacks normality between episoe intensity an associate with vasomotor symptoms, nausea, an vomiting. Criteria A. At least five attacks fulfilling criteria B-D B. Attacks of abominal pain lasting 1 to 72 hours C. Abominal pain has all the following characteristics: 1. Miline location, periumbilical or poorly localize 2. Dull or just sore quality 3. Moerate to severe intensity D. During abominal pain, at least 2 of the following: 1. Anorexia 2. Nausea 3. Vomiting 4. Pallor E. Not attribute to another isorer; history an physical examination finings o not suggest gastrointestinal or renal isease, or such isease has been rule out by appropriate investigations foun that AM i persist into the late teens in 38% of their 54 cases. SYMPTOMATOLOGY AM symptoms are characterize by acute episoic, miline periumbilical abominal pain that is ull in nature, lasting for several hours to ays, an associate with flushing, pallor, anorexia, nausea, vomiting, an photophobia (Lewis, 2009). Symptoms recur at least twice a year, an the chil is typically pain free in between episoes. A family history of migraine heaaches is common. In a prospective stuy, researchers reviewe 150 case histories of AM over a 10-year perio. A family history of cephalic migraines in first-egree relatives was ientifie in 90% of cases (Bentley, Kehely, Al- Bayaty, & Michie, 1995). A clinical retrospective survey of 5848 peiatric ambulatory patients reveale that 65% of cases with AM/cyclical vomiting ha a family history of migraine (Al-Twaijri & Shevell, 2002). In a 2005 stuy, Stickler (2005) also reporte that mothers an granmothers of patients with AM were twice as likely to experience migraines when compare with a control group with no migraine history. Brams introuce the term abominal migraine nearly a century ago, in He believe the conition was uner-iagnose by gastroenterologists an neurologists. The onset of abominal pain was escribe BOX 2. Rome III iagnostic criteria* for abominal migraine For a iagnosis of abominal migraine, all of the following must apply: 1. Paroxysmal episoes of intense, acute periumbilical pain that lasts for 1 hour or more 2. Intervening perios of usual health lasting weeks to months 3. Pain interferes with normal activities 4. Pain is associate with two or more of the following: a. Anorexia b. Nausea c. Vomiting. Heaache e. Photophobia f. Pallor 5. No evience of an inflammatory, anatomic, metabolic, or neoplastic process consiere that explains the patient s symptoms *Criteria fulfille two or more times in the preceing 12 months. as abrupt, recurrent, an persistent for 3 to 4 ays an ening just as abruptly. The interval between attacks of pain was symptom free (Brams, 1922). Dignan et al. (2001) thought it was common for peiatric abominal pain to give way to migraine heaaches. They tracke 54 chilren with AM into young aulthoo an foun that 70% were present or past sufferers of migraine heaaches, compare with only 20% of matche control subjects. Other researchers suggest that AM, cyclic vomiting synrome, an migraine heaache comprise a continuum of a single isorer an that affecte iniviuals often progress from one clinical symptom to another (Abu-Arafeh & Russell, 2002). Cyclic vomiting synrome an AM have been use interchangeably, but there are significant ifferences to support their separation, mainly the presence or absence of migraine heaache (Catto-Smith & Ranuh, 2003). The principle textbook on migraines, The Heaaches, secon eition (2000), evote a chapter on migrainerelate synromes in chilren, incluing AM. Because of wiesprea acceptance by health care proviers of AM as a unique iagnostic entity, the Heaache Classification Subcommittee of the International Heaache Society (2004) inclue AM in the secon eition of their classification within the group Chilhoo perioic synrome precursor of migraine an coe it as PATHOPHYSIOLOGY Several hypotheses have been investigate to etermine the pathogenesis an pathophysiology of abominal migraine pain. Factors inclue IgE-meiate iet-inuce allergy, gut mucosal immune responses, phenol sulfotransferase enzyme M an P catabolism November/December

3 of catecholamines an monoamines, an the permeability of the gut mucosal surface (Bentley et al., 1995). Weyert, Ball, an Davis (2003) iscusse the relationship between the gut an the central nervous system (CNS). Derive from the same embryologic tissues, the enteric nervous system an CNS have irect effects on each other. These investigators propose that stress increases CNS arousal, uring which neuropepties an neurotransmitters are release. This situation, in turn, leas to ysregulation of the gastrointestinal system. While the consistent symptom is episoic abominal pain with clear-cut symptom-free intervals, the pathophysiology of pain is beyon the scope of this iscussion. CASE STUDY A 15-year-ol girl presente as a new patient with intermittent episoes of abominal pain an vomiting since infancy, occurring up to four times per month. Symptoms inclue non-raiating abominal pain an vomiting. Pain was not relieve with bowel movements or position change an continue for 24 hours. There were no ientifie triggers, an heaache was enie. No other associate symptoms were reporte. Previous evaluations inclue a complete bloo cell count with ifferential, a complete metabolic panel, erythrocyte seimentation rate, urinalysis, urine culture, serum human chorionic gonaotropin, thyroi stuies, serum amino an urine organic acis, lipase, amylase, toxicology, an hemoglobin electrophoresis; all results were normal. Finings of an abominal x-ray, abominal/renal ultrasoun, an upper gastrointestinal stuy with small bowel follow-through also were normal. Past meications inclue Zofran (onansetron) an Phenergan (promethazine) without improvement. Fioricet, prescribe for the mother s migraine heaaches, was marginally effective. Nonpharmacologic treatment failures inclue ietary restrictions an stress reuction strategies. There is a reporte history of migraine heaache in the patient s mother. Her examination was within normal limits in all systems. The chil s history an symptoms met ICHD-II criteria for AM. Successful treatment inclue aministration of prophylactic tricyclic antiepressants. Follow-up evaluation reveale a marke reuction in episoes of abominal pain. DIAGNOSIS When accompanie by a history of migraine heaaches, the iagnosis of AM is straightforwar (Collins & Thomas, 2007). AM is exclue, however, if any of the following are present: mil symptoms not interfering with aily activities; burning pain; non-miline abominal pain; symptoms consistent with foo allergy or other gastrointestinal isease; attacks lasting less than 1 hour; or persistence of symptoms between attacks (Lewis, Yonker, Winner, & Sowell, 2005). In all other cases, the iagnosis shoul remain presumptive, an other causes of intermittent severe abominal pain shoul be consiere an systematically exclue. In contrast to acute an chronic abominal pain, an explanation for recurrent abominal pain is selom foun (Russell et al., 2002). It is estimate that only 5% to 10% of chilren with recurrent abominal pain have an unerlying organic process that contributes to their pain (Weyert et al., 2003). The health care provier must conuct a thorough physical examination an obtain the health history of the chil an his or her family. Collins an Thomas (2007) ientifie re flag signs an symptoms suggestive of organic iseases (Box 3), which suggest a higher likelihoo of pathology requiring subspecialty referral an possible enoscopy. Catto-Smith an Ranuh (2003) recommene initial iagnostic stuies (Box 4), an Diamon (2002) avocate for the consistent inclusion of appenicitis, volvulus, bowel malrotation, an posterior fossa tumors as part of the AM ifferential iagnosis. Ultimately, iagnosis is base on the meical history, absence of abnormality, an fulfillment of recognize criteria. MANAGEMENT Treatment an management of AM in chilren shoul be kept simple an are etermine by the severity, frequency, an impact on the aily life of the chil an BOX 3. Re flags suggesting further workup neee Unexplaine subjective an objective finings incluing: Ultimately, iagnosis is base on the meical history, absence of abnormality, an fulfillment of recognize criteria. Change in growth patterns inclues height an weight Recurrent unexplaine fevers Pain raiating to the back Bilious emesis Visible or occult bloo in stool Chronic iarrhea (lasting >2 weeks an >20 ml/kg per ay) Mouth ulcers Dysphagia Rashes with no ientifiable cause Nighttime symptoms Arthritis Anemia Pale mucus membranes Delaye puberty Family history of inflammatory bowel isease 374 Volume 24 Number 6 Journal of Peiatric Health Care

4 his or her family. Accoring to recently publishe finings, the Franklin (1952) approach remains the cornerstone for management of AM: explanation, reassurance, search for possible triggers, an behavioral approaches (Russell, Symon, & Abu-Arafeh, 2007). Severe an protracte episoes of emesis, however, may warrant hospitalization an require intravenous fluis to counteract ehyration. NONPHARMACOLOGIC THERAPY Because minimal ata are available regaring AM treatment, Lewis et al. (2005), Russell et al. (2002), an Diamon (2002) offere experiential an anecotal rather than evience-base nonpharmacologic recommenations, beginning with family eucation an avoiance of triggers. Suggeste strategies for ientifie triggers inclue the following: BOX 4. Initial iagnostic stuies for consieration in chilren presenting with possible cyclic vomiting synrome or abominal migraine Bloo stuies Hemoglobin, white count an ifferential C-reactive protein Electrolytes, creatinine an glucose Liver function tests Pancreatic enzymes Pregnancy test Urine an stool stuies Urinalysis with microscopy an culture Stool occult bloo an microscopy Raiologic stuies Ultrasoun of liver, gall blaer, biliary tract, pancreas, arenal glans, an kineys Upper GI series Magnetic resonance imaging or CT of brain Enoscopy Esophagogastrouoenoscopy Colonoscopy with ileoscopy (to exclue Crohn s isease) Data from Pareek, Fleisher, & Abell, Effective coping strategies to prevent an relieve stress Betime fiber snack to prolong the glycemic effect an avoi hypoglycemia an relate acute morning attacks Frequent travel stops to prevent motion sickness Routine betime to prevent altere sleep patterns Use of a hat or sunglasses to eliminate glare an iminish bright lights Use of a iet low in amines, which inclues many foo that begin with the letter C that is, chocolate, cocoa, citrus, caffeine (cola, coffee, tea), cheese, an colorings (in sweets an chewing gum); aitives such as monosoium glutamate (MSG); currants, raisins, an black grapes; an flavorings such as those in snacks like potato chips Ientifying specific foos by restricting the iet an graually re-introucing foos over a 2-week perio PHARMACOLOGIC THERAPY Abnormal concentrations of vasoactive amines, such as norarenaline an serotonin, typically are foun in aults who have migraine heaaches. Anti-migraine rugs are intene to prevent the painful events by interfering with the biochemical pathways. There are no stuies evaluating similar biochemical imbalances in chilren with AM; however, pharmacologic management in the treatment of migraine heaaches has prove to be effective in treatment of AM (Tan, Sahami, Peebles, & Shaw, 2006). Lewis et al. (2005) also suggeste that treatment guielines for migraine heaaches may prove to be efficacious for the management of AM. In the practice guielines publishe in 2004, Lewis et al. summarize ata from numerous stuies that focuse on abortive treatment, specifically nasal sumatriptan, as well as preventive treatment of migraines in chilren, noting that similar treatment has been proven effective in persons with AM. Catto-Smith an Ranuh (2003) foun tricyclic antiepressants to be effective prophylactic agents, an Lewis, Winner, Hershey, an Wasiewski (2007) also foun propranolol (2 to 4 mg/kg/ay) an cyproheptaine (0.25 to 1.5 mg/kg) to be effective. Lewis (2009) also note that cyproheptaine at a starting ose of 2 to 4 mg at betime is a simple, effective, an safe strategy for chilren younger than 10 years who are not overweight. Lewis (2007) incorporates the work of a number of other researchers (Ahonen, Hamalainen, Rantala, & Hoppu, 2004; Major, Grubisa, & Thie, 2003; Uberall, 2001; Winner et al., 2000) when he states the following: The agents stuie most rigorously for the acute treatment of migraine [heaache] are ibuprofen (10 mg/kg/ose), acetaminophen (10-15 mg/kg/ ose) for chilren uner 12 years of age, an sumatriptan nasal spray, all of which have shown safety an efficacy in controlle trials (2007, p. 50). Although none of the selective serotonin receptor agonists or triptans have been approve by the Foo an Drug Aministration for use with chilren an aolescents, multiple stuies have emonstrate their safety for chilren s use (Major et al., 2003). Thus far, only sumatriptan in the nasal spray form, 5 an 20 mg, has emonstrate efficacy in aolescents (Ahonen et al., 2004; Lewis et al., 2004; Uberall, 2001; Winner et al., 2000). In their review of the literature for peiatric migraines, Shah an Kalra (2009) observe that oral November/December

5 formulations of selective serotonin receptor agonists were not beneficial in chilren. Zolmitriptan nasal spray (2.5 to 5 mg), emonstrate efficacy when evaluate in 12-to 17-year-ol chilren (Lewis et al., 2007). Lewis an colleagues practice parameters (2004) aresse the limitations of pharmacologic agents, reporting inconclusive ata regaring preventive treatment of migraine heaaches. They conclue that further research is warrante before specific pharmacologic agents can be suggeste. (An up-to-ate reference list for AM is available online at the Web site for the Cyclic Vomiting Synrome Association: NURSING PRACTICE IMPLICATIONS Initial consieration of the iagnosis of AM is warrante if a chil presents with intermittent severe abominal pain without an ientifiable cause. Symptom-free perios between episoes are essential to the iagnosis. A thorough history an physical examination is essential to rule out any physical causes of pain. The iagnosis shoul be mae after other organic causes are rule out. Initial episoes may mimic appenicitis or obstruction, an often an abominal scan is neee to rule out acute processes. The provier shoul encourage the caregiver to ocument the frequency of episoes, precipitating factors, an treatment interventions. A symptom iary can ientify triggers an effective treatment strategies. Pharmacologic.use of the Rome III an ICHD-II criteria to ai in iagnosis may consierably shorten what has been a typically protracte evaluation process. an non-pharmacologic measures shoul be attempte, an caregivers shoul be eucate about the potential averse effects of pharmacologic treatment. The goal of therapy is to abort episoes quickly to prevent interference with aily activities. Referrals to neurology an psychology specialists may be necessary for alternative treatments such as biofeeback if interventions are not successful. CONCLUSION AM, along with organic causes, must be consiere in any chil presenting with severe episoic abominal pain, with or without heaache. A thorough history an physical is essential for making the iagnosis, an use of the Rome III an ICHD-II criteria to ai in iagnosis may consierably shorten what has been a typically protracte evaluation process. Caregiver eucation about management of symptoms is also essential, an treatment shoul be iniviualize, because patient responses to treatment will vary. Pharmacologic treatment is currently limite but has been implemente in chilren who o not respon to nonpharmacologic therapy an whose symptoms have a negative impact on aily activities. The overall goal of treatment is to limit occurrence of episoes an thus improve quality of life for chilren an aolescents who have this isorer. REFERENCES Abu-Arafeh, I., & Russell, G. (2002). Chilhoo heaache. Cambrige, MA: Cambrige University Press. Ahonen, K., Hamalainen, M. L., Rantala, H., & Hoppu, K. (2004). Nasal sumatriptan is effective in the treatment of migraine attacks in chilren. Neurology, 62, Al-Twaijri, W. A., & Shevell, M. I. (2002). Peiatric migraine equivalents: Occurrence an clinical features in practice. Peiatric Neurology, 26(5), Bentley, D., Kehely, A., Al-Bayaty, M., & Michie, C. A. (1995). Abominal migraine as a cause of vomiting in chilren: A clinician s view. Journal of Peiatric Gastroenterology an Nutrition, 21(Suppl. 1), S49-S51. Brams, W. A. (1922). Abominal migraine. Journal of the American Meical Association, 78, Catto-Smith, A. G., & Ranuh, R. (2003). Abominal migraine an cyclical vomiting. Seminars in Peiatric Surgery, 12(4), Collins, B. S., & Thomas, D. W. (2007). Chronic abominal pain. Peiatrics in Review, 28(9), Diamon, S. (2002). An approach to the patient with abominal migraine. (Heaache of the month). Consultant, 42(10), Dignan, F., Abu-Arafeh, I., & Russell, G. (2001). The prognosis of chilhoo abominal migraine. Archives of Disease in Chilhoo, 84(4), Franklin, A. W. (1952). Perioic isorers of chilren. Lancet, ii, Heaache Classification Subcommittee of the International Heaache Society. (2004). Classification an iagnostic criteria for heaache isorers, cranial neuralgias, an facial pain. (2n e.) Cephalalgia, 24(Suppl. 1), Lewis, D., Ashwal, S., Hershey, A., Hirtz, D., Yonker, M., & Silberstein, S. (2004). Practice parameters: Pharmacological treatment of migraine heaache in chilren an aolescents: Report of the American Acaemy of Neurology Quality Stanars Subcommittee an the Practice Committee of the Chil Neurology Society. Neurology, 63, Lewis, D. W., Yonker, M., Winner, P., & Sowell, M. (2005). The treatment of peiatric migraine. Peiatric Annals, 34(6), Lewis, D. W. (2007). Peiatric migraine. Peiatrics in Review, 28(2), Lewis, D. W. (2009). Peiatric migraine. Neurologic Clinics, 27(2), Major, P., Grubisa, H., & Thie, N. (2003). Triptans for the treatment of acute peiatric migraine: A systematic literature review. Peiatric Neurology, 29, Pareek, N., Fleisher, D., & Abell, T. (2007). Cyclic vomiting synrome: what a gastroenterologist nees to know. American Journal of Gastroenterology, 102(12), Rasquin, A., Di Lorenzo, C., Forbes, D., Guirales, E., Hyams, J. S., Staiano, A., & Walker, L. S. (2006). Chilhoo functional gastrointestinal isorers: Chil/aolescent. Gastroenterology, 130(5), Russell, G., Abu-Arafeh, I., & Symon, D. N. K. (2002). Abominal migraine: Evience for existence an treatment options. Peiatric Drugs, 4(1), Volume 24 Number 6 Journal of Peiatric Health Care

6 Russell, G., Symon, D. N. K., & Abu-Arafeh, I. (2007). The chil with recurrent abominal pain: Is it abominal migraine? British Journal of Hospital Meicine, 68(7), M110-M113. Shah, U. H., & Kalra, V. (2009). Peiatric migraine. International Journal of Peiatrics, 2009,1-7. Stickler, G. B. (2005). Relationship between cyclic vomiting synrome an migraine. Clinical Peiatrics, 44(6), Tan, V., Sahami, A. R., Peebles, R., & Shaw, R. J. (2006). Abominal migraine an treatment with intravenous valproic aci. Psychosomatics, 47(4), Uberall, M. (2001). Sumatriptan in paeiatric an aolescent migraine. Cephalalgia, 24(Suppl 1), Weyert, J. A., Ball, T. M., & Davis, M. F. (2003). Systematic review of treatments for recurrent abominal pain. Peiatrics, 111(1), e1-e11. Winner, P., Rothner, A. D., Saper, J., Nett, R., Asgharneja, M., & Laurenza, R. A. (2000). A ranomize, ouble-blin, placebo-controlle stuy of sumatriptan nasal spray in the treatment of acute migraine in aolescents. Peiatrics, 105(5), WANTED: CASE STUDIES The JPHC is seeking case stuies in Primary Care an Acute & Specialty Care that you woul like to share with the reaers. Please contact the appropriate eitor with your name, aress (incluing ), an topic. A template for you to follow along with eitorial support makes this easy, fun, an professionally rewaring. Manuscripts can be submitte online at CONTACT INFORMATION: Primary Care Eitors Jo Ann Serota, MS, RN, CPNP, [email protected] Corresponing Eitor Beverly P. Giorano, MS, RN, CPNP, [email protected] Donna Hallas, PhD, PNP-BC, CPNP, [email protected] Acute & Specialty Care Eitors Anrea Kline, MS, RN, CPNP-PC/AC, CCRN, FCCM, [email protected] Corresponing Eitor Terea Giannetta, MSN, RN, CPNP, [email protected] Karin Reuter-Rice, PhD, CPNP, [email protected] November/December