Abdominal migraine is a variant of migraine, seen associated with classic migraine but is not characterized by migraine headaches. Instead, abdominal migraines manifest as abdominal pain, specifically in the middle of the abdomen around the navel area.
It mostly affects children of five to nine years of age but may affect adults too. The abdominal pain is usually described as a dull ache in the abdomen which may be moderate to severe pain. Also, the pain is not consistently present and occurs in episodes lasting for 2 to 72 hours with intermittent symptom-free periods.
The exact cause of abdominal migraine is unclear. Some people believe that changes in the level of two compounds namely histamine and serotonin in the body may be the causative mechanism involved in the development of abdominal migraine. Genetic factors are also held responsible for the development of abdominal migraine as 40 per cent of children with abdominal migraine have a family member with classic migraine. Researchers also believe that abdominal migraine shares trigger factors with classic migraine headaches, including nitrate-containing foods such as chocolates, processed foods, etc. along with anxiety, stress and swallowing of excessive air.
Diagnosis of abdominal migraine is extremely challenging for the physicians as there is no definitive test to diagnose it. However, it is important to recognize the condition early as children with abdominal migraine tend to develop classic migraine headaches once they reach adulthood. Hence, effective preventive strategies can be taken to counteract the progression of this disease. Once diagnosed, it can be effectively managed through medications and preventive strategies.
Symptoms
- Abdominal migraine presents with following symptoms.
- Abdominal pain in the mid-line
- Loss of appetite
- Vomiting
- Pallor
- Nausea
- Drowsiness or low on energy
Treatment
Abdominal migraine is usually treated like other migraines. Symptomatic relief and prevention of episodes are the goals of treatment of abdominal migraine.
Medications such as Non-steroidal anti-inflammatory drugs (NSAIDs), anti-nausea and antiemetic drugs as well as specific anti-migraine drug, i.e. triptans constitute the chief medications used in the treatment of abdominal migraine. Adequate fluid intake is also important to alleviate the dehydration associated with persistent severe vomiting.
Prevention of abdominal migraine forms another major component of managing the disease. A diet diary should be maintained to recognize the specific food that triggers the episodes. Refrain from potential triggers such as chocolates and processed foods. If stress is the trigger factor, Cognitive Behavioral Therapy (CBT) should be initiated to help the child adapt to stressful situations. Maintaining a good routine involving enough sleep, regular meals and adequate hydration can also help manage the condition.
However, these preventive approaches may not be effective in moderate to severe cases of abdominal migraine. In such cases of recurrent migraine episodes, regular medications may be needed, including beta-blockers, tricyclic antidepressants (TCAs), calcium channel blockers (CCBs), anticonvulsants and non-selective antihistaminic drugs.
The drugs used in the treatment of abdominal migraine are described below.
Drugs for Symptomatic Relief of Abdominal Migraine
1. Non-steroidal Anti-inflammatory Drugs (NSAIDs)
This group of drugs block the synthesis and release of a chemical, known as prostaglandins. This chemical induces pain and inflammation. An enzyme, called cyclooxygenase enzyme (COX) enzyme is required to produce prostaglandins. NSAIDs block COX enzyme and thus inhibit the release of prostaglandins. By doing so, it relieves the abdominal pain experienced in abdominal migraine.
Available as: Oral preparations
I. Aspirin
US-FDA Status: Approved for abdominal migraine
Availability: Over-the-counter
Generic name: aspirin/ acetaminophen/ caffeine
Brand name: Excedrin tablet
Side-effects: Hives, itching, rash, upset stomach, coughing up blood, black,red or tarry stools, blood in urine
Indicated in pregnancy: Absolutely contraindicated in third trimester as it may affect the fetal cardiovascular system
Alcohol content: Absent
II. Acetaminophen
US-FDA Status: Approved for abdominal migraine
Availability: Over-the-counter
Generic name: acetaminophen
Brand name: Tylenol tablet
Side-effects: Bloody or cloudy urine, black or tarry stools, hives, skin rash, sore fatigue
Indicated in pregnancy: Only if absolutely indicated
Alcohol content: Absent
III. Ibuprofen
US-FDA Status: Approved for abdominal migraine
Availability: Over-the-counter
Generic name: ibuprofen
Brand name: Motrin IB tablet
Side-effects: Bloating, belching, acidity, cloudy urine, diarrhea, heartburn, decreased amount of urine
Indicated in pregnancy: Absolutely contraindicated in third trimester as it may affect the fetal cardiovascular system
Alcohol content: Absent
IV. Diclofenac
US-FDA Status: Approved for abdominal migraine
Availability: Prescription only
Generic name: diclofenac
Brand name: Zorvolex capsule
Side-effects: Bloating, cloudy urine, belching, constipation, dizziness
Indicated in pregnancy: Absolutely contraindicated in third trimester as it may affect the fetal cardiovascular system
Alcohol content: Absent
NSAIDs are also used in the treatment of other conditions, such as back pain, toothache, menstrual cramps, arthritis, etc.
2. Antiemetics and Anti-nausea Drugs
Vomiting can be bothersome in abdominal migraine. It occurs due to stimulation of vomiting center situated in the brain. There are various receptors present in this vomiting center, such as histamine, dopamine, cholinergic, serotonin, etc.
Various antiemetics can be used to relieve nausea and vomiting seen in abdominal migraine.
I. H1 Antihistaminics
These drugs strongly block specific receptors namely cholinergic and histamine and are weak blockers of dopamine receptors. By doing so, they suppress the vomiting center of the brain, thus relieving nausea and vomiting in abdominal migraine. They are mostly available in combination with NSAIDs.
Available as: Oral preparations and Injectable preparations
A. Promethazine
US-FDA Status: Approved for abdominal migraine
Availability: Prescription only
Generic name: promethazine hydrochloride
Brand name: Promethazine plain syrup (oral), Promethazine Hydrochloride (injection)
Side-effects: Seizures, high fever, fast heartbeat, high blood pressure
Indicated in pregnancy: Only if absolutely indicated
Alcohol content: Present (about 7% alcohol)
B. Diphenhydramine
US-FDA Status: Approved for abdominal migraine
Availability: Over-the-counter
Generic name: diphenhydramine citrate/ ibuprofen (oral), diphenhydramine hydrochloride (injection)
Brand name: Advil PM tablet (oral), Diphenhydramine hydrochloride (injection)
Side-effects: Rash, hives, chest pain, dizziness, black tarry stools
Indicated in pregnancy: Only if benefit outweighs fetal risk
Alcohol content: Absent
The H1 antihistaminics are also used to relieve chemotherapy-induced nausea and vomiting.
II. Neuroleptics
This group of drugs blocks dopamine receptors present in the vomiting center of the brain, thus relieves nausea and vomiting seen in abdominal migraine.
Available as: Oral preparations, Suppositories and Injectable preparations
A. Prochlorperazine
US-FDA Status: Approved for abdominal migraine
Availability: Prescription
Generic name: prochlorperazine (suppository), prochlorperazine edisylate (injection)
Brand name: Compro (suppository), Prochlorperazine Edisylate (injection)
Side-effects: Agitation, chest pain, constipation, clay-colored stools, dark urine, diarrhea
Indicated in pregnancy: Usually not indicated in third trimester
Alcohol content: Absent
III. Prokinetic drugs
These are potent antiemetics and they also promote gastric emptying by increasing the motility of gastric muscles.
Available as: Oral preparations and Injectable preparations
A. Metoclopramide
This drug acts on dopamine and serotonin receptors of the vomiting center of brain, thus produce an anti-emetic action.
US-FDA Status: Approved for abdominal migraine
Availability: Prescription
Generic name: metoclopramide hydrochloride
Brand name: Metozolv ODT tablet (oral), Metoclopramide Hydrochloride (injection)
Side-effects: Dark urine, chills, clay colored stools, dizziness, difficulty breathing, fever, loose stools, muscle dystonia
Indicated in pregnancy: Only if benefit outweighs fetal risk
Alcohol content: Absent
B. Domperidone
US-FDA Status: Unapproved for abdominal migraine
Availability: Not available in U.S. but it is available in other countries
Generic name: domperidone
Brand name: Domperidone
Side-effects: Dry mouth, diarrhea, abdominal cramps, breast tenderness, gynaecomastia
Indicated in pregnancy: Only if benefit outweighs fetal risk
Alcohol content: Absent
Prokinetic drugs are also used in the treatment of GERD and diabetic gastroparesis.
3. Anti-migraine Drugs
I. Triptans
This group of drugs act by enhancing the effects of a brain chemical, known as serotonin, i.e., they are serotonin agonist. They produce this stimulatory effect by acting on certain serotonin receptors namely 5-hydroxytryptamine 1B (5-HT1B) and 5-hydroxytryptamine 1D (5-HT1D). By doing so, they constrict the blood vessels of brain and reduce inflammation of the brain tissue. Thus, they are potent anti-migraine drugs used in the treatment of migraine headaches.
However, their role in combating abdominal migraine is still unclear.
A. Sumatriptan
It is usually indicated as a first-line drug in treating migraine headaches not responding to NSAIDs.
A research suggested that nasal sumatriptan may prove effective in treating abdominal migraine in adults. However, its safe administration in children with abdominal migraine is still a matter of controversy. [1]
Available as: Oral preparations, Nasal preparations and Injectable preparations
US-FDA Status: Approved for abdominal migraine
Availability: Prescription
Generic name: sumatriptan succinate (oral and injectable preparations), sumatriptan (nasal spray)
Brand name: Imitrex tablets, Imitrex injections, Sumatriptan nasal spray
Side-effects: Mild headache, drowsiness, dizziness, feeling cold or hot
Indicated in pregnancy: Only if absolutely indicated
Alcohol content: Absent
Drugs for Prophylaxis of Abdominal Migraine
Increased frequency of abdominal migraine attacks, can be very disturbing for the patient. Hence, in such cases regular medications may be used to reduce the onset of abdominal migraine episodes. These medications constitute the “prophylaxis of abdominal migraine”. These medications are described below.
1. Beta- blockers
This class of drugs is known for its efficiency in treating various health conditions, such as angina, hypertension, arrhythmia, heart failure, anxiety, etc. The therapeutic use of beta-blockers is based on the blockade of beta adrenergic receptors present in the heart and blood vessels.
Beta-blockers are most commonly used drugs in the prophylactic treatmenHungaryt of abdominal migraine. However, the use of beta-blockers in the prevention of abdominal migraine attacks is not known.
Available as: Oral preparations
I. Propranolol
US-FDA Status: Approved for abdominal migraine
Availability: Prescription
Generic name: propranolol hydrochloride
Brand name: Hemangeol oral solution
Side-effects: Cough with mucous, trouble breathing, chest tightness, black tarry stools, blood in urine
Indicated in pregnancy: Only if absolutely indicated
Alcohol content: Absent
2. Tricyclic Antidepressants
This group of drugs potentiates the action of serotonin, which is a mood elevator, hence combats depression. It can produce dramatic results in mental health disorders, such as panic disorder.
However, its exact role in preventing the onset of episodes of abdominal migraine is unknown. It is especially indicated in abdominal migraine in presence of a concomitant depression. But, since it produces more side-effects as compared to beta-blockers, it is not preferred over beta- blockers in the prophylactic treatment of abdominal migraine.
Available as: Oral preparations
I. Amitriptyline
US-FDA Status: Approved for abdominal migraine
Availability: Prescription
Generic name: amitriptyline hydrochloride
Brand name: Amitriptyline Hydrochloride tablet
Side-effects: Agitation, blurred vision, bleeding gums, black tarry stools, blood in urine, chills, cold sweats
Indicated in pregnancy: Only if absolutely indicated
Alcohol content: Absent
3. Calcium Channel Blockers (CCBs)
This group of drugs is commonly prescribed for conditions, such as hypertension, angina, Raynaud’s disease, etc. As the name implies, these drugs block the calcium channels and prevent the inflow of calcium ions in the cells of heart and blood vessels, thus validating its therapeutic use.
However, they have also been seen to reduce the frequency of abdominal migraine attacks. The exact mechanism by which it helps prevent the onset of abdominal migraine episodes is not clear.
Available as: Oral preparations
I. Verapamil
US-FDA Status: Approved for abdominal migraine
Availability: Prescription
Generic name: verapamil hydrochloride
Brand name: Calan tablet
Side-effects: Blurred vision, confusion, chest pain, cough with sputum, difficulty breathing
Indicated in pregnancy: Only if absolutely indicated
Alcohol content: Absent
CCBs are not as effective as beta-blockers in the prophylaxis of abdominal migraine.
4. Anti-convulsant Drugs
These drugs are commonly advocated in the treatment of convulsions or epilepsy or seizures (commonly referred to as “fits”). They alter the sodium ion channels and/or potentiate the effect of a brain chemical, known as gamma- Aminobutyric acid (GABA), thus are beneficial in epilepsy.
However, some of them are effective in preventing the episodes of abdominal migraine attacks as well. Various anti-convulsants used in the prophylactic treatment of abdominal migraine are as follows.
Available as: Oral preparations
I. Valproic acid
US-FDA Status: Approved for abdominal migraine
Availability: Prescription
Generic name: valproic acid
Brand name: Depakene capsule
Side-effects: Bleeding gums, black tarry stools, blood in urine, confusion, bloating, cough
Indicated in pregnancy: Usually contraindicated
Alcohol content: Absent
II. Gabapentin
US-FDA Status: Approved for abdominal migraine
Availability: Prescription
Generic name: gabapentin
Brand name: Neurontin capsule
Side-effects: Unsteadiness, constant back and forth or rolling eye movements, anxiety, aggression, difficulty in concentrating
Indicated in pregnancy: Only if benefit outweighs fetal risk
Alcohol content: Absent
III. Topiramate
US-FDA Status: Approved for abdominal migraine
Availability: Prescription
Generic name: topiramate
Brand name: Topamax tablet
Side-effects: Unsteadiness, confusion, vision problems, drowsiness
Indicated in pregnancy: Usually contraindicated
Alcohol content: Absent
5. Non- selective 5-HT antagonist
This group of drugs blocks 5-HT or serotonin receptors. However, they also act on other receptors, such as cholinergic, adrenergic, histaminic, etc. Hence, they are known as Non- selective 5-HT antagonist. Various non- selective 5-HT antagonists used in preventing abdominal migraine attacks are as follows.
I. Cyproheptadine
It primarily blocks 5-HT2a receptors (i.e., serotonin receptors), cholinergic receptors and H1 antihistaminic receptors. However, its use in preventing abdominal migraine episodes is based on its action on H1 histaminic receptors and its action on growth hormones.
Available as: Oral preparations
US-FDA Status: Approved for abdominal migraine
Availability: Prescription
Generic name: cyproheptadine hydrochloride
Brand name: Cyproheptadine Hydrochloride tablet
Side-effects: Drowsiness, sleepiness, restlessness, disturbed coordination, excitation
Indicated in pregnancy: Only if benefit outweighs fetal risk
Alcohol content: Absent
Because of its antihistaminic action, it is also used in the treatment of allergies and hives.
II. Pizotifen
It belongs to a drug class, known as benzocycloheptene. This drug acts on serotonin receptors namely 5-HT2A and 5-HT2C receptors. It also has antihistaminic and anticholinergic action.
The blockade of serotonin receptors may be held responsible for its use in preventing abdominal migraine attacks.
Available as: Oral preparations
US-FDA Status: Unapproved for abdominal migraine
Availability: Not available
Generic name: pizotifen
Brand name: Pizotifen
Side-effects: Drowsiness, sleepiness, tiredness, dry mouth
Indicated in pregnancy: Only if benefit outweighs fetal risk
Alcohol content: Absent
OTC
There are several over-the-counter medications for treating abdominal migraine. However, their availability varies from country to country.
Over-the-counter drugs for abdominal migraine in different countries have been described in the table below.
| Name of the Country | OTC Drug(s) Available |
| Argentina | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diclofenac (oral) Diphenhydramine (oral) |
| Australia | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diclofenac (oral) Diphenhydramine (oral) Prochlorperazine (oral) Promethazine (oral) Metoclopramide (oral) Cyproheptadine (oral) |
| Austria | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diphenhydramine (oral) |
| Canada | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diphenhydramine (oral) Promethazine (oral) Cyproheptadine (oral) |
| China | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diclofenac (oral) Diphenhydramine (oral) Promethazine (oral) Domperidone (oral) Cyproheptadine (oral) |
| Croatia | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) |
| Czech Republic | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diclofenac (oral) Diphenhydramine (oral) Domperidone (oral) |
| Denmark | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diphenhydramine (oral) Cyproheptadine (oral) |
| France | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diphenhydramine (oral) Promethazine (oral) Cyproheptadine (oral) |
| Germany | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diclofenac (oral) Diphenhydramine (oral) |
| Greece | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diclofenac (oral) Diphenhydramine (oral) Promethazine (oral) |
| Hungary | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diclofenac (oral) Diphenhydramine (oral) |
| India | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) |
| Ireland | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diphenhydramine (oral) Promethazine (oral) Domperidone (oral) |
| Italy | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diclofenac (oral) Diphenhydramine (oral) Promethazine (oral) Metoclopramide (oral) |
| Japan | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diphenhydramine (oral) Promethazine (oral) |
| Mexico | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diclofenac (oral) Diphenhydramine (oral) Sumatriptan (oral) |
| Philippines | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diphenhydramine (oral) |
| Russia | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diclofenac (oral) Diphenhydramine (oral) |
| Singapore | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diphenhydramine (oral) Promethazine (oral) Domperidone (oral) Cyproheptadine (oral) |
| South Africa | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Promethazine (oral) Diclofenac (oral) |
| South Korea | Promethazine (oral) Metoclopramide (oral) Domperidone (oral) Cyproheptadine (oral) |
| Spain | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diclofenac (oral) Diphenhydramine (oral) Promethazine (oral) |
| Switzerland | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diclofenac (oral) Diphenhydramine (oral) Promethazine (oral) Domperidone (oral) |
| The Netherlands | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diclofenac (oral) |
| UK | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diphenhydramine (oral) Prochlorperazine (oral) Promethazine (oral) Sumatriptan (oral) Cyproheptadine (oral) |
| USA | Acetylsalicylic acid (oral) Acetaminophen (oral) Ibuprofen (oral) Diphenhydramine (oral) |
Abdominal migraine can be a difficult condition to be diagnosed and treated. Hence, seek a doctor’s consultation to effectively manage the condition. Self-medication is not recommended.
