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Abdominal Migraine in Children: Is It All in Their Heads?
Continuing Education
Abdominal Migraine in Children: Is It All in Their Heads? Aixa I. Catala-Beauchamp, FNP-BC, and Robyn P. Gleason, ARNP
ABSTRACT Abdominal migraine in children is a migraine variant, described as isolated, paroxysmal attacks of severe periumbilical abdominal pain associated with nausea, vomiting, pallor, anorexia, headache, and photophobia, with intervening periods of normality. Abdominal migraine is a diagnosis of exclusion, as presenting symptomatology can also be characteristic of other disease processes. An extensive history and physical examination are necessary to differentiate between abdominal migraine and acute abdominal pain. Limited studies have been conducted on the management of children with an acute abdominal migraine attack. Treatment and prophylaxis of acute attacks is essential to reduce recurrence, severity, and extent of pain. Keywords: abdominal migraine, childhood periodic syndromes, chronic abdominal pain, functional abdominal pain, migraine subtypes, migraine syndrome © 2012 American College of Nurse Practitioners
Aixa I. Catala-Beauchamp, DNP, MSN, MA, FNP-BC, is a pediatric hospitalist for Florida Pediatric Associates, providing medical rounds for hospitalized pediatric patients at Florida Hospital in Orlando. She can be reached at [email protected]. Robyn P. Gleason, PhD, MSN, MPH, ARNP, is associate professor at the University of Florida College of Nursing in Gainesville. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. This CE learning activity is designed to augment the knowledge, skills, and attitudes of nurse practitioners and assist in their understanding of diagnosis and treatment of abdominal migraine in children. At the conclusion of this activity, the participant will be able to: A. Identify diagnostic criteria of abdominal migraine in children/adolescents B. Distinguish abdominal migraine from functional abdominal pain C. Delineate effective treatment for prevention and acute attacks The authors, reviewers, editors, nurse planners, and pilot testers all report no financial relationships that would pose a conflict of interest. The authors do not present any off-label or non-FDA-approved recommendations for treatment. There is no implied endorsement by NPA or ANCC of any commercial products mentioned in the article.
Readers may receive the 1.0 CE credit free by reading the article and answering each question online at www.npjournal.org, or they may mail the test answers and evaluation, along with a processing fee check for $10 made out to Elsevier, to PO Box 540, Ellicott City, MD 21041-0540. Required minimum passing score is 70%. This educational activity is provided by Nurse Practitioner Alternatives™. NPA™ is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
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“I feel like I have a headache in my stomach,” KM, 11 years old
A
bdominal migraine (AM) is one of the most challenging diagnoses in children. Despite the increased recognition of AM in children in the past decade, the diagnosis remains controversial. The correlation between headache and abdominal pain has been a well-known phenomenon since the early 1900s. Buchanan in 1921 and Brams in 1922 were the first to propose the term AM to explain abdominal pain attacks not associated with headaches yet with analogous features to migraine headaches.1 In 1988 the diagnosis of AM was established by the International Headache Society (IHS). A study conducted in 1993 by Mortimer, Kay, and Jaron2 was one of the first to follow the IHS criteria for AM. They studied the epidemiology of AM in children with a history of recurrent abdominal pain in an urban general practice. They found that AM occurred in 2%-4% of schoolchildren between the ages of 3 and 10, was significantly higher in girls, had a peak prevalence between the ages of 5 and 7 (particularly in children with a maternal history of migraine), and was associated with travel sickness. After this study, in 1995 Abu-Arafeh and Russell3 studied the incidence and etiology of headache and abdominal pain among 2,165 Aberdeen schoolchildren 515 years old. They found that 10.6% of these children met the IHS criteria for the diagnosis of migraine, 4.1% for the diagnosis of AM, and 24% for both. They also found that the clinical features of AM recurrence, common triggers, alleviating factors, associated symptomatology, and duration of symptoms were similar to those with migraine headache. Based on these findings, they concluded that a common pathogenesis exists between migraine headache and AM. They recommended adherence to the IHS diagnostic criteria for the diagnosis of AM for children who present with recurrent abdominal pain. This research has been cited in the childhood periodic syndromes literature as one of the first studies to follow the initial AM criteria described by IHS, which was a precursor to the current criteria. Beginning in 1995, Bentley et al4 conducted a 10year prospective study of 150 children who presented with recurrent abdominal pain, 46% of whom had symptoms consistent with AM. Of those, 90% had a firstdegree relative with a history of migraine headache. This longitudinal study further contributed to the development of diagnostic criteria for the diagnosis of AM. 20
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Despite the controversy surrounding the classification of idiopathic, periodic, and severe attacks of abdominal pain in children as AM, it was incorporated into the International Classification of Headache Disorders (ICHD) by the IHS (with revised criteria) in 2004.5 In 2006 the term was also incorporated to the Rome III Pediatric Criteria for functional gastrointestinal disorders (FGID) in children.7 Since its integration to the ICHD and the Rome 6 III, there has been extensive disagreement on the number of events essential for diagnosis of AM. A Brazilian study9 was conducted among 1,113 children 5-12 years old and registered in public elementary school. The investigators reviewed the incidence of childhood periodic syndromes and their correlation with headache, migraine headache, and tension-type headaches. Arruda and colleagues9 reported that recurrent abdominal pain was the most common symptom (32.9% prevalence), more than double any of the other complaints. They reported significant association between symptoms seen in periodic syndromes and the 3 tested migraine subtypes. They also observed that interictal symptoms were independently associated with all 3 types of headaches. They concluded that childhood periodic syndromes in children are associated with migraine and migraine subtypes and tension headache. SCOPE OF THE PROBLEM The incidence of AM ranges from 2.4% to 4.1% among children 7-12 years old, is more common in girls, and occasionally continues into adult years.8 AM is considered to be a diagnosis of exclusion. CASE STUDY An 11-year-old girl presented to the emergency department (ED) with acute onset of severe abdominal pain in the periumbilical area, nausea, vomiting, and pallor. According to the mother, she was doing well until 2 hours before presentation to the ED, when unexpectedly she started to complain of vague abdominal pain that quickly escalated in intensity to the point of doubling over, throwing herself to the ground, vomiting, and developing a “ghostly” appearance. Review of symptoms was otherwise unremarkable. Past medical history revealed recurring attacks of severe abdominal pain since age 7, prompting extensive laboratory and radiological investigations with negative Volume 8, Issue 1, January 2012
results, including multiple endoscopies with no evidence abdominal pain may be associated with other migraine of gastrointestinal diseases. The family gastrointestinal hisprodromes, such as tiredness and sleepiness.10 tory was unremarkable, with no reports of inflammatory Although AM pain is usually located in the peribowel disease, celiac disease, or renal or metabolic disorumbilical area, midline pain or poorly localized pain ders. However, the patient’s described as either dull or mother and several maternal sore in nature can also aunts reported a history of occur.1,11 The pain is associmigraine headaches. ated with any 2 additional When acute abdominal On examination in the ED features that may include pain with an established the patient was afebrile, in no anorexia, nausea, vomiting, diagnosis transforms to a acute respiratory distress, and headache, photophobia, and chronic pattern, further had a completely normal physipallor.10 Pain onset and resocal examination. Workup lution are unpredictable; they investigation is warranted. included abdominal X-ray, hinder daily activities and abdominal ultrasound, computschool attendance during erized tomography (CT) scan attacks and disrupt family life. Each episode self-resolves. Complete resolution of of the abdomen and pelvis, blood cell count, complete symptoms between attacks is an important criterion to metabolic panel, amylase, lipase, liver enzymes, C-reactive differentiate from chronic abdominal pain. protein, and urinalysis, which were all normal. She was In addition, while chronic abdominal pain has been given IV ondansetron (Zofran®; GlaxoSmithKline, Triangle Park, NC) for the nausea, intravenous fluid associated with psychological dysfunction or psychiatric bolus, and IV toradol for the pain. After several hours in comorbidities, this is not the case in AM. A systematic litthe ED, her pain resolved, and she was discharged home erature review by Brujin and colleagues12 demonstrated to be followed by primary care. that somatic complains of children with AM, such as However, the patient returned to the ED 12 hours headache, nausea, vomiting, and abdominal pain, are an later with worsening abdominal pain, nausea, vomiting, outcome of their illness, not an indication of psychologiand headache. She was hospitalized for further evaluation cal or psychiatric problems. and treatment. Once again, extensive investigative As it is a diagnosis of exclusion, differentiating the workup was negative. She was treated with IV toradol diagnosis of AM is challenging and must include a and famotidine with some relief. She continued to comthorough history, detailed review of symptoms, complain of severe, paroxysmal pain, and when asked about plete physical examination, and appropriate investigathe pain, she said, “I feel like I have a headache in my tive studies that rule out any other disorders.13 The stomach.” This prompted a neurology consult. She was history must include a detailed account of recurring diagnosed with AM, treated with almotriptan with resoabdominal pain and associated symptomatology, exaclution of headache and abdominal pain, and discharged erbating and alleviating factors (including medicahome on nasal sumatripan for preventive treatment. tions), state of health between attacks, laboratory and radiological studies done in the past that have DIAGNOSTIC CRITERIA excluded any other processes potentially explaining AM attacks are diagnosed by the presenting symptoms of the child’s symptoms, and family medical history of paroxysmal, periodic episodes of recurrent, severe abdommigraine. A thorough physical examination should be inal pain of variable duration and intensity in otherwise essentially negative except for abdominal tenderness, healthy children with a noncontributory physical examiwhich (if present) is usually diffuse and mild. nation and completely negative workup.10 The characterInflammatory, infectious, organic, or neoplastic causes istic pain may last from hours to several days, with and any other probable causes of recurrent abdominal intensity that varies from moderate to severe. It may be pain, either relating to the gastrointestinal tract or coupled with dramatic reactions, such as holding the extra-abdominal causes, should be ruled out by approabdomen, doubling over, or falling to the floor. The priate studies. It is vital that the diagnostic criteria for www.npjournal.org
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Table 1. 2004 International Classification of Headache Disorders II Criteria for Abdominal Migraine1
Table 2. 2006 Rome III Diagnostic Criteriaa for Abdominal Migraine8
1.3.2 Abdominal migraine
Must include all of the following:
A. At least 5 attacks fulfilling criteria B-D
1. Paroxysmal episodes of intense, acute periumbilical pain that lasts for 1 hour or more
B. Attacks of abdominal pain lasting 1 to 72 hours C. Abdominal pain has all the following characteristics: 1. Midline location, periumbilical or poorly localized 2. Dull or ‘‘just sore’’ quality 3. Moderate to severe intensity D. During abdominal pain, at least 2 of the following: 1. Anorexia 2. Nausea 3. Vomiting 4. Pallor E. Not attributed to another disorder; history and physical examination findings do not suggest gastrointestinal or renal disease, or such disease has been ruled out by appropriate investigations
2. Intervening periods of usual health lasting weeks to months 3. Pain interferes with normal activities 4. Pain is associated with 2 or more of the following: a. Anorexia b. Nausea c. Vomiting d. Headache e. Photophobia f. Pallor 5. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process considered that explains the patient’s symptoms aCriteria
AM, as established by ICHD-II, be met 2 or more times in the prior year. PATHOPHYSIOLOGY The pathophysiology of AM in children is not fully understood. Several theories have attempted to explain the pathways that trigger migraine variant attacks. Recent studies have recognized migraine variants as a familial disease. It has been suggested that the processing of pain signals by the central nervous system (CNS) is a genetically inherited phenomenon. It has also been postulated that the susceptibility to the cellular excitability of the trigeminal-vascular system leads to hyperexcitability of neuropeptides that regulate pain receptors, both in the CNS and in the abdomen.14 The constant interaction of genetic and environmental factors contributes to the development of central and enteric nervous systems.15 Opiates, the neuropeptides involved in the regulation of pain information, are considered to play a central role in the pathogenesis of abdominal pain. As these neuropeptides are stimulated by innocuous stimuli, such as stress, generalized visceral hyperalgesia occurs, contributing to gastrointestinal dysmotility and pain.15 Transient mucosal inflammation as a response to mechanical or chemical stimuli may also intensify enteric nerve sensitivity, which could also contribute to the characteristic AM pain. The events responsible for associated symptoms seen in AM are thought to be caused by the hypothalamic-pitu22
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fulfilled 2 or more times in the preceding 12 months.
itary-adrenal axis system response to stress, which causes the stereotypical attacks and associated symptoms, such as pallor, nausea, vomiting, and sensory-motor abnormalities.15 DIFFERENTIAL DIAGNOSIS AM is a diagnosis of exclusion based on the stereotypical clinical presentation, in the absence of underlying disorders for abdominal pain and with 2 or more associated features as established by the ICHD-II and the Rome III criteria guidelines13,16 (Tables 1 and 2). The abdominal pain in AM must be differentiated from chronic or functional abdominal pain. Chronic abdominal pain, in the absence of organic causes, is often related to emotional stress; the pain is “constant” and localized in the periumbilical area, the child is reluctant to attend school, and physical examination is usually negative except for mild generalized tenderness the exam.15 In contrast, AM attacks are sporadic in nature, with complete resolution of pain between attacks, the pain in the periumbilical region is intense, it interferes with daily activities, and there is a positive family history for migraine headaches.18 The initial differential diagnosis of AM in children must include a thorough evaluation to identify any underlying process of abdominal pain for which prompt management may change the outcome. The 2 main diagnostic categories that must be ruled out before diagnosing AM are organic disorders and functional disorders. Volume 8, Issue 1, January 2012
Organic disorders that contribute to chronic abdominal and avoiding trigger factors. Daily diaries of child’s activipain in children include inflammatory bowel disease, ties, diet, stressful situations, exercise, and symptoms can Crohn’s disease, malabsorption, celiac disease, food allergies, help to identify triggers. Parental guidance on alternative infectious processes, drug triggers, musculoskeletal pain, and prophylactic remedies should include lifestyle modificaupper gastrointestinal abnormalities (gastritis, esophagitis, tions, avoidance of ill-coping mechanisms to deal with gastroesophageal reflux, peptic ulcers), Helicobacter pylori, attacks, stress management, travel, sleeping habits, and gallbladder disease, kidney stones, urologic disorders, environmental factors, such as very bright or irideschronic pancreatitis, duodenal obstruction, sickle cell anecent/strobe lights, diet, and exercise. The STRESS mia crisis, gynecologic disorders (such as Mittelschmerz, mnemonic (Table 3) was developed by one of this articongenital uterine anomalies, recurrent ovarian cysts), poscle’s authors as an educational guide for providers and a terior fossa tumors, and seizure disorders if the child prespractical handout for parents. This guide was formulated ents with recurrent syncope or loss of consciousness.1,4,6 based on current literature and internet sources. Functional gastrointestinal disorders are conditions in which the child suffers from recurrent abdominal pain TREATMENT either as a neurobiological disorder, somatic response to Once underlying or acute processes have been ruled out 17 stress, or secondary gain. These disorders include funcand the diagnosis of AM has been established, therapeutic tional abdominal pain, chronic abdominal pain syndrome, approaches should include both pharmacological and irritable bowel syndrome, functional dyspepsia, chronic non-pharmacological measures. To date, limited research constipation, and aerophagia. The abdominal pain in AM is has been conducted in the treatment of AM in children. differentiated from chronic abdominal pain by the sporadic Current treatment modes for acute attacks focus on lessnature of the pain, location and duration, interference with ening symptoms and are based on anecdotal experience daily activities during the attack, and family history of with the disease, rather than evidence from clinical trials. migraine headaches.18 When acute abdominal pain with an The treatment goal of AM is to elicit prompt sympestablished diagnosis transforms to a chronic pattern, further tom relief and reintegration of the child to normality as investigation is warranted. soon as possible without furAM attacks can overlap ther setbacks. An effective therwith acute abdominal processes apeutic approach is adapted to and may be precipitated by the child and family based on The cornerstone of acute illnesses. For instance, the child’s symptomatology, treatment is preventing emesis accompanied by severe prior response to treatment, abdominal pain with or withand the family’s sociocultural recurrent attacks by out fever may indicate superhealth values, which may guide identifying and avoiding imposed disease process, such as their adherence to the treattrigger factors. appendicitis, Meckle’s diverticment recommended. An approulitis, bowel obstruction, volvupriate multidisciplinary team lus from malrotation, acute approach should include councholelithiasis, ureteropelvic junction obstruction, urolithiseling the parents and child while formulating a plan for asis, pyelonephritis, new onset diabetes mellitus in diaschool reintegration, along with referral for psychological betic ketoacidosis, and Munchausen syndrome by counseling if maladaptive coping mechanisms are 19 proxy. Any emesis accompanied by acute changes in present.19 Parental assurance, reassurance, and education neurological condition as evidenced by focal neurologic are vital components of the treatment. Russell and colfindings indicates increased intracranial pressure, seizures, leagues3 reported successful outcomes when parents were or metabolic disorder, requiring immediate action. assured that there was no severe abdominal pathology in the child. PREVENTION Parents of children diagnosed with AM should be Parents must be made aware that the cornerstone of reassured that complementary and alternative therapies treatment is preventing recurrent attacks by identifying during an acute pain exacerbation may help and should www.npjournal.org
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Table 3. STRESS Mnemonic for Prevention of Abdominal Migraine in Children S (Stress management)
Avoid stress and anxiety as much as possible Allow your child to have downtime during highly stressful situations
T (Travel tips)
Anticipate possible triggers related to travel such as motion sickness, altitude changes, disrupted sleep patterns, “wrong foods,” dehydration, and temperature fluctuations During travel, ensure that your child gets enough rest and maintains a regular sleep schedule, healthy diet, regular exercise, and consistent behavioral management
R (Rest)
Avoid irregular sleep patterns (either deprivation or excess sleep) Upon onset of the pain, provide a dark and quiet room for your child; sleep is the best treatment for a migraine attack
E (Emergency signs requiring medical attention)
Fever: either new onset or recurrent inexplicable fevers Unexplained weight loss or failure to grow Abdominal distress, such as vomiting bile, diarrhea, bloody stools, persistent pain between attacks Pain that wakens the child from sleep or radiation of pain to the back Mouth ulcers, difficulty swallowing
S (Sparkling lights)
Avoid prolonged exposure to strobes/flashing lights, bright flickering lights, such as the TV and computer screen
S (Snacks to avoid)
Foods containing caffeine (cola, chocolate, coffee, tea) Aged, overcooked, and processed meats; aged chesses, dried and canned fish Condiments: meat extracts, monosodium glutamate, soy sauce, vegemite, vinegar, Worstershire sauce Fruits: avocado, ripening banana, dates, kiwifruit, figs, grapes, lemon, lime, mandarin, orange, passion fruit, pineapple, plum, raspberry, tangerine Meats: any aged or frozen meat, bacon, beef liver, chicken liver, chicken skin, ham, pork, salami, sausage Snack foods: Brazil nuts, cheese or spicy-flavored snack foods, coconut, English mackernut, pecan, peanut, sesame seeds, sunflower seeds, walnut (black) Vegetables: broccoli, eggplant, sauerkraut, cauliflower, dill pickles, mushrooms, olives, spinach, tomato Fish: anchovies, fish marinades, fish meat, herring, mackerel, salami, salmon, dried sardines, canned tuna Dairy products: brie, cheddar, cracker barrel, Danish blue, gouda, mozzarella, Munster, parmesan, provolone, romano, Swiss
be tried before seeking pharmacologic treatment.1 In helping a child suffering from AM, providers can teach parents and children helpful coping strategies to deal with pain, such as relaxation techniques through deepbreathing and guided imagery to lessen stress. During an attack, the parent should allow the child to rest in a quiet, dark room until symptoms subside and reassure the child that this will be helpful. Table 4 outlines medications for AM in children. Over-the-counter analgesics and antiemetics often provide sufficient relief.1,18,20 If the pain escalates, prescription pharmacological treatment might be necessary. Limited data were found concerning appropriate prescription pharmacological management of AM attacks in children. Current pharmacological treatment is based 24
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on expert opinion and experience with medications used for migraine headaches, given the lack of wellcontrolled clinical trials.11 Additionally, data on the use of migraine headache drugs to treat abdominal migraines have been limited to children whose symptoms are not relieved by alternative therapies, when symptoms are severe and disabling. Anecdotal evidence reveals that AM attacks have been treated successfully in the pediatric population with triptans.18 Almotriptan, intranasal sumatriptan, and zolmitriptan are the most widely used drugs for migraine attacks and the only medications approved for acute attacks in adolescents.20 To date, almotriptan is the only medication approved by the Food and Drug Administration for the acute treatment of migraine in 12- to 17-year-olds,20,21 Volume 8, Issue 1, January 2012
Table 4. Medications for Management of Abdominal Migraine in Children Dosea
Medication Acute attacks Acetaminophen
15 mg/kg/dose every 4-6 hours as needed; max of 5 doses/day or 4gm/dayb
Ibuprofen
10 mg/kg/dose every 6-8 hours as needed; max of 40 mg/kg/day or 2.4 gm/dayb
Almotriptan
6.25-12.5 mg upon onset of migraine, may be repeated in 2 hours; max 25 mg/day (only for adolescents ⬎ 12 years)
Sumatriptan, intranasal
5-20 mg as soon as possible after the onset of pain, may repeat same dose after 2 hours; max 40 mg/dayb
Zolmitriptan, intranasal
2.5-5 mg as soon as possible after the onset of pain, may repeat same dose after 2 hours; max 10 mg/dayb
Prophylaxis (Based on anecdotal evidence rather than controlled trials) Amitriptylinec
1-1.5 mg/kg per day given before bedtime, max 300 mg/day
Propranololc
10 mg BID-TID
Cyproheptadinec
0.25-0.5 mg/kg/day divided TID
Valproic
acidc
Topiramatec
250-1000 mg divided BID 25-100 mg divided BID
aDose
based on literature recommendations23 bUse the lowest effective dose for the shortest period to reduce the risk of adverse reactions cInitiate treatment with lower dose; increase dose based on patient response
and intranasal sumatriptan and zolmitriptan have been approved by the European Medicines Agency (EMEA). Intranasal sumatriptan, one of the 7 available triptans studied in the United States, has been considered efficacious and safe for the acute treatment phase, based on the 2004 American Academy of Neurology management guidelines for acute migraine management in children.22 Nasal sumatriptan has been reported to be more effective than placebo in relieving headache, nausea, and vomiting during an acute migraine attack in the pediatric population20,21 and has been anecdotally used for AM attacks with similar success. The use of intranasal sumatriptan in children with AM is an off-label use and requires caution as serious adverse effects and death have been reported in children after its use.23 Adverse reactions to sumatriptan include acute cardiovascular effects, such as myocardial infarction, hypertension, life-threatening arrhythmias, stroke; gastrointestinal discomfort, such as nausea and vomiting; and neuromuscular and skeletal effects, such as weakness, myalgia, numbness, hyperreflexia, and meningismus.23 Lewis and colleagues24 examined the use of zolmitriptan nasal spray in 171 adolescents during a migraine attack. Intranasal zolmitriptan was well-tolerated and showed statistically significantly greater headache www.npjournal.org
relief and sustained resolution of associated migraine symptoms than placebo. The use of this spray for AM is also off-label, and its adverse effects are similar to those in intranasal sumatriptan. Tricyclic antidepressants, selective serotonin reuptake inhibitors, and anticholigernics are among the most common medications for AM prophylaxis.20, 21 The most common prophylactic medications in adolescents and adults reported in the literature are amitriptyline, propranolol, cyproheptadine, valproic acid, and topiramate.1,20,22 There are limited studies in children regarding prophylaxis therapy for AM. Until further studies are conducted and standardized criteria established, pharmacological prophylaxis treatment of AM in children should be deferred to pediatric neurologists. CONCLUSION The incidence and significance of AM in children is underappreciated, although the disease has been firmly established among headache authorities. Limited studies have been conducted on the management of AM in children, and recent findings advise the use of a multidisciplinary approach that includes pharmacologic and non-pharmacologic measures for prevention of AM in children and for treatment during AM exacerbations. Parental reassurance and education are critical components of treatment. The The Journal for Nurse Practitioners - JNP
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ultimate goal is to find the best treatment mode to reduce exacerbations, with the aim of improving the quality of life for children and their families. References 1. Cuvellier JC, Lepine A. Childhood periodic syndromes. Pediatr Neurol. 2010;42(1):1-11. 2. Mortimer MJ, Kay J, Jaron A. Clinical epidemiology of childhood abdominal migraine in an urban general practice. Develop Med Child Neurol. 1993;35(3):243-248. 3. Abu-Arafeh I, Russell G. Childhood Headache. Cambridge, MA: Cambridge University Press; 2002. 4. Bentley D, Kehely A, al-Bayaty M, Michie C. Abdominal migraine as a cause of vomiting in children: A clinician’s view. J Pediatr Gastroenterol Nutr. 1995;21(suppl 1):S49-51. 5. Headache Classification Subcommittee of the International Headache Society Classification and diagnostic criteria for headache disorders, cranial neuralgias, and facial pain. 2nd ed. Cephalgia. 2004;24(suppl 1):1-160. 6. Dooley JM, Pearlman EM. The clinical spectrum of migraine in children. Pediatr Ann. 2010;39(7):408-415. 7. Abend NS, Younkin D, Lewis DW. Secondary headaches in children and adolescents. Semin Pediatr Neurol. 2010;17(2):123-133. 8. Rasquin A, Di Lorenzo C, Forbes D, et al. Childhood functional gastrointestinal disorders: Child/adolescent. Gastroenterology. 2006;130(5):1527-1537. 9. Arruda MA, Guidetti V, Galli F, Albuquerque RC, Bigal ME. Childhood periodic syndromes: A population-based study. Pediatr Neurol. 2010;43(6):420-424. 10. Srinivasa R, Kumar R. Migraine variants and beyond. J Assoc Physicians India. 2010;58(suppl):14-17. 11. Popovich DM, Schentrup DM, McAlhany AL. Recognizing and diagnosing abdominal migraines. J Pediatr Health Care. 2010;24(6):372-377. 12. Brujin J, Locher H, Passchier J, Dijkstra N, Arts WF. Psychopathology in children and adolescents with migraine in clinical studies: A systematic review. Pediatrics. 2010;126(2):323-332. 13. Kabbouche MA, Cleves C. Evaluation and management of children and adolescents presenting with an acute setting. Semin Pediatr Neurol. 2010;17:105-108. 14. Ravishankar K. Migraine—The new understanding. J Assoc Physicians India. 2010;58(suppl):30-33. 15. Saps M, Li BU. Chronic abdominal pain of functional origin in children. Pediatr Ann. 2006;35(4):246-256. 16. Baber KF, Anderson J, Puzanovova M, Walker LS. J Pediatr Gastroenterol Nutr. 2008;47(3):299-302. 17. Li BU. Functional abdominal pain in children: New understanding, diagnostic criteria, and treatment approaches. Pediatr Ann. 2009;38(5):241-242. 18. Lewis DW, Pearlman E. The migraine variants. Pediatr Ann. 2005;34(6):486-497. 19. Ammoury RF, Pfefferkorn, MR, Croffie JM. Functional gastrointestinal disorders: Past and present. World J Pediatr. 2009;5(2):103-112. 20. Russell G, Abu-Arafeh I, Symon D. Abdominal migraine: evidence for existence and treatment options. Paediatr Drugs. 2002;4(1):1-8. 20. Papetti L, Spalice A, Nicita F, et al. Migraine treatment in developmental age: Guidelines update. J Headache Pain. 2010;11:267-276. 21. Hershey AD. Current approaches to the diagnosis and management of paediatric migraine. Lancet Neurology, 2010;9(2):190-204. 22. Eiland LS, Hunt MO. The use of triptans for pediatric migraines. Pediatr Drugs. 2010;12(6):379-389. 23. Taketomo CK, Hodding J H, Kraus DM. Pediatric Dosage Handbook. 17th ed. Hudson, OH: Lexi-Comp, Inc.; 2010. 24. Lewis DW, Winner P, Hershey AD, et al. Adolescent migraine steering committee. Efficacy of zolmitriptan nasal spray in adolescent migraine. Pediatrics. 2007;120:390-396. 1555-4155/12/$ see front matter © 2012 American College of Nurse Practitioners doi: 10.1016/j.nurpra.2011.06.007
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Volume 8, Issue 1, January 2012
Abdominal Migraine in Children: Is It All in Their Heads? Aixa I. Catala-Beauchamp, FNP-BC, and Robyn P. Gleason, ARNP
ABSTRACT Abdominal migraine in children is a migraine variant, described as isolated, paroxysmal attacks of severe periumbilical abdominal pain associated with nausea, vomiting, pallor, anorexia, headache, and photophobia, with intervening periods of normality. Abdominal migraine is a diagnosis of exclusion, as presenting symptomatology can also be characteristic of other disease processes. An extensive history and physical examination are necessary to differentiate between abdominal migraine and acute abdominal pain. Limited studies have been conducted on the management of children with an acute abdominal migraine attack. Treatment and prophylaxis of acute attacks is essential to reduce recurrence, severity, and extent of pain. Keywords: abdominal migraine, childhood periodic syndromes, chronic abdominal pain, functional abdominal pain, migraine subtypes, migraine syndrome © 2012 American College of Nurse Practitioners
Aixa I. Catala-Beauchamp, DNP, MSN, MA, FNP-BC, is a pediatric hospitalist for Florida Pediatric Associates, providing medical rounds for hospitalized pediatric patients at Florida Hospital in Orlando. She can be reached at [email protected]. Robyn P. Gleason, PhD, MSN, MPH, ARNP, is associate professor at the University of Florida College of Nursing in Gainesville. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. This CE learning activity is designed to augment the knowledge, skills, and attitudes of nurse practitioners and assist in their understanding of diagnosis and treatment of abdominal migraine in children. At the conclusion of this activity, the participant will be able to: A. Identify diagnostic criteria of abdominal migraine in children/adolescents B. Distinguish abdominal migraine from functional abdominal pain C. Delineate effective treatment for prevention and acute attacks The authors, reviewers, editors, nurse planners, and pilot testers all report no financial relationships that would pose a conflict of interest. The authors do not present any off-label or non-FDA-approved recommendations for treatment. There is no implied endorsement by NPA or ANCC of any commercial products mentioned in the article.
Readers may receive the 1.0 CE credit free by reading the article and answering each question online at www.npjournal.org, or they may mail the test answers and evaluation, along with a processing fee check for $10 made out to Elsevier, to PO Box 540, Ellicott City, MD 21041-0540. Required minimum passing score is 70%. This educational activity is provided by Nurse Practitioner Alternatives™. NPA™ is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
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“I feel like I have a headache in my stomach,” KM, 11 years old
A
bdominal migraine (AM) is one of the most challenging diagnoses in children. Despite the increased recognition of AM in children in the past decade, the diagnosis remains controversial. The correlation between headache and abdominal pain has been a well-known phenomenon since the early 1900s. Buchanan in 1921 and Brams in 1922 were the first to propose the term AM to explain abdominal pain attacks not associated with headaches yet with analogous features to migraine headaches.1 In 1988 the diagnosis of AM was established by the International Headache Society (IHS). A study conducted in 1993 by Mortimer, Kay, and Jaron2 was one of the first to follow the IHS criteria for AM. They studied the epidemiology of AM in children with a history of recurrent abdominal pain in an urban general practice. They found that AM occurred in 2%-4% of schoolchildren between the ages of 3 and 10, was significantly higher in girls, had a peak prevalence between the ages of 5 and 7 (particularly in children with a maternal history of migraine), and was associated with travel sickness. After this study, in 1995 Abu-Arafeh and Russell3 studied the incidence and etiology of headache and abdominal pain among 2,165 Aberdeen schoolchildren 515 years old. They found that 10.6% of these children met the IHS criteria for the diagnosis of migraine, 4.1% for the diagnosis of AM, and 24% for both. They also found that the clinical features of AM recurrence, common triggers, alleviating factors, associated symptomatology, and duration of symptoms were similar to those with migraine headache. Based on these findings, they concluded that a common pathogenesis exists between migraine headache and AM. They recommended adherence to the IHS diagnostic criteria for the diagnosis of AM for children who present with recurrent abdominal pain. This research has been cited in the childhood periodic syndromes literature as one of the first studies to follow the initial AM criteria described by IHS, which was a precursor to the current criteria. Beginning in 1995, Bentley et al4 conducted a 10year prospective study of 150 children who presented with recurrent abdominal pain, 46% of whom had symptoms consistent with AM. Of those, 90% had a firstdegree relative with a history of migraine headache. This longitudinal study further contributed to the development of diagnostic criteria for the diagnosis of AM. 20
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Despite the controversy surrounding the classification of idiopathic, periodic, and severe attacks of abdominal pain in children as AM, it was incorporated into the International Classification of Headache Disorders (ICHD) by the IHS (with revised criteria) in 2004.5 In 2006 the term was also incorporated to the Rome III Pediatric Criteria for functional gastrointestinal disorders (FGID) in children.7 Since its integration to the ICHD and the Rome 6 III, there has been extensive disagreement on the number of events essential for diagnosis of AM. A Brazilian study9 was conducted among 1,113 children 5-12 years old and registered in public elementary school. The investigators reviewed the incidence of childhood periodic syndromes and their correlation with headache, migraine headache, and tension-type headaches. Arruda and colleagues9 reported that recurrent abdominal pain was the most common symptom (32.9% prevalence), more than double any of the other complaints. They reported significant association between symptoms seen in periodic syndromes and the 3 tested migraine subtypes. They also observed that interictal symptoms were independently associated with all 3 types of headaches. They concluded that childhood periodic syndromes in children are associated with migraine and migraine subtypes and tension headache. SCOPE OF THE PROBLEM The incidence of AM ranges from 2.4% to 4.1% among children 7-12 years old, is more common in girls, and occasionally continues into adult years.8 AM is considered to be a diagnosis of exclusion. CASE STUDY An 11-year-old girl presented to the emergency department (ED) with acute onset of severe abdominal pain in the periumbilical area, nausea, vomiting, and pallor. According to the mother, she was doing well until 2 hours before presentation to the ED, when unexpectedly she started to complain of vague abdominal pain that quickly escalated in intensity to the point of doubling over, throwing herself to the ground, vomiting, and developing a “ghostly” appearance. Review of symptoms was otherwise unremarkable. Past medical history revealed recurring attacks of severe abdominal pain since age 7, prompting extensive laboratory and radiological investigations with negative Volume 8, Issue 1, January 2012
results, including multiple endoscopies with no evidence abdominal pain may be associated with other migraine of gastrointestinal diseases. The family gastrointestinal hisprodromes, such as tiredness and sleepiness.10 tory was unremarkable, with no reports of inflammatory Although AM pain is usually located in the peribowel disease, celiac disease, or renal or metabolic disorumbilical area, midline pain or poorly localized pain ders. However, the patient’s described as either dull or mother and several maternal sore in nature can also aunts reported a history of occur.1,11 The pain is associmigraine headaches. ated with any 2 additional When acute abdominal On examination in the ED features that may include pain with an established the patient was afebrile, in no anorexia, nausea, vomiting, diagnosis transforms to a acute respiratory distress, and headache, photophobia, and chronic pattern, further had a completely normal physipallor.10 Pain onset and resocal examination. Workup lution are unpredictable; they investigation is warranted. included abdominal X-ray, hinder daily activities and abdominal ultrasound, computschool attendance during erized tomography (CT) scan attacks and disrupt family life. Each episode self-resolves. Complete resolution of of the abdomen and pelvis, blood cell count, complete symptoms between attacks is an important criterion to metabolic panel, amylase, lipase, liver enzymes, C-reactive differentiate from chronic abdominal pain. protein, and urinalysis, which were all normal. She was In addition, while chronic abdominal pain has been given IV ondansetron (Zofran®; GlaxoSmithKline, Triangle Park, NC) for the nausea, intravenous fluid associated with psychological dysfunction or psychiatric bolus, and IV toradol for the pain. After several hours in comorbidities, this is not the case in AM. A systematic litthe ED, her pain resolved, and she was discharged home erature review by Brujin and colleagues12 demonstrated to be followed by primary care. that somatic complains of children with AM, such as However, the patient returned to the ED 12 hours headache, nausea, vomiting, and abdominal pain, are an later with worsening abdominal pain, nausea, vomiting, outcome of their illness, not an indication of psychologiand headache. She was hospitalized for further evaluation cal or psychiatric problems. and treatment. Once again, extensive investigative As it is a diagnosis of exclusion, differentiating the workup was negative. She was treated with IV toradol diagnosis of AM is challenging and must include a and famotidine with some relief. She continued to comthorough history, detailed review of symptoms, complain of severe, paroxysmal pain, and when asked about plete physical examination, and appropriate investigathe pain, she said, “I feel like I have a headache in my tive studies that rule out any other disorders.13 The stomach.” This prompted a neurology consult. She was history must include a detailed account of recurring diagnosed with AM, treated with almotriptan with resoabdominal pain and associated symptomatology, exaclution of headache and abdominal pain, and discharged erbating and alleviating factors (including medicahome on nasal sumatripan for preventive treatment. tions), state of health between attacks, laboratory and radiological studies done in the past that have DIAGNOSTIC CRITERIA excluded any other processes potentially explaining AM attacks are diagnosed by the presenting symptoms of the child’s symptoms, and family medical history of paroxysmal, periodic episodes of recurrent, severe abdommigraine. A thorough physical examination should be inal pain of variable duration and intensity in otherwise essentially negative except for abdominal tenderness, healthy children with a noncontributory physical examiwhich (if present) is usually diffuse and mild. nation and completely negative workup.10 The characterInflammatory, infectious, organic, or neoplastic causes istic pain may last from hours to several days, with and any other probable causes of recurrent abdominal intensity that varies from moderate to severe. It may be pain, either relating to the gastrointestinal tract or coupled with dramatic reactions, such as holding the extra-abdominal causes, should be ruled out by approabdomen, doubling over, or falling to the floor. The priate studies. It is vital that the diagnostic criteria for www.npjournal.org
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Table 1. 2004 International Classification of Headache Disorders II Criteria for Abdominal Migraine1
Table 2. 2006 Rome III Diagnostic Criteriaa for Abdominal Migraine8
1.3.2 Abdominal migraine
Must include all of the following:
A. At least 5 attacks fulfilling criteria B-D
1. Paroxysmal episodes of intense, acute periumbilical pain that lasts for 1 hour or more
B. Attacks of abdominal pain lasting 1 to 72 hours C. Abdominal pain has all the following characteristics: 1. Midline location, periumbilical or poorly localized 2. Dull or ‘‘just sore’’ quality 3. Moderate to severe intensity D. During abdominal pain, at least 2 of the following: 1. Anorexia 2. Nausea 3. Vomiting 4. Pallor E. Not attributed to another disorder; history and physical examination findings do not suggest gastrointestinal or renal disease, or such disease has been ruled out by appropriate investigations
2. Intervening periods of usual health lasting weeks to months 3. Pain interferes with normal activities 4. Pain is associated with 2 or more of the following: a. Anorexia b. Nausea c. Vomiting d. Headache e. Photophobia f. Pallor 5. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process considered that explains the patient’s symptoms aCriteria
AM, as established by ICHD-II, be met 2 or more times in the prior year. PATHOPHYSIOLOGY The pathophysiology of AM in children is not fully understood. Several theories have attempted to explain the pathways that trigger migraine variant attacks. Recent studies have recognized migraine variants as a familial disease. It has been suggested that the processing of pain signals by the central nervous system (CNS) is a genetically inherited phenomenon. It has also been postulated that the susceptibility to the cellular excitability of the trigeminal-vascular system leads to hyperexcitability of neuropeptides that regulate pain receptors, both in the CNS and in the abdomen.14 The constant interaction of genetic and environmental factors contributes to the development of central and enteric nervous systems.15 Opiates, the neuropeptides involved in the regulation of pain information, are considered to play a central role in the pathogenesis of abdominal pain. As these neuropeptides are stimulated by innocuous stimuli, such as stress, generalized visceral hyperalgesia occurs, contributing to gastrointestinal dysmotility and pain.15 Transient mucosal inflammation as a response to mechanical or chemical stimuli may also intensify enteric nerve sensitivity, which could also contribute to the characteristic AM pain. The events responsible for associated symptoms seen in AM are thought to be caused by the hypothalamic-pitu22
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fulfilled 2 or more times in the preceding 12 months.
itary-adrenal axis system response to stress, which causes the stereotypical attacks and associated symptoms, such as pallor, nausea, vomiting, and sensory-motor abnormalities.15 DIFFERENTIAL DIAGNOSIS AM is a diagnosis of exclusion based on the stereotypical clinical presentation, in the absence of underlying disorders for abdominal pain and with 2 or more associated features as established by the ICHD-II and the Rome III criteria guidelines13,16 (Tables 1 and 2). The abdominal pain in AM must be differentiated from chronic or functional abdominal pain. Chronic abdominal pain, in the absence of organic causes, is often related to emotional stress; the pain is “constant” and localized in the periumbilical area, the child is reluctant to attend school, and physical examination is usually negative except for mild generalized tenderness the exam.15 In contrast, AM attacks are sporadic in nature, with complete resolution of pain between attacks, the pain in the periumbilical region is intense, it interferes with daily activities, and there is a positive family history for migraine headaches.18 The initial differential diagnosis of AM in children must include a thorough evaluation to identify any underlying process of abdominal pain for which prompt management may change the outcome. The 2 main diagnostic categories that must be ruled out before diagnosing AM are organic disorders and functional disorders. Volume 8, Issue 1, January 2012
Organic disorders that contribute to chronic abdominal and avoiding trigger factors. Daily diaries of child’s activipain in children include inflammatory bowel disease, ties, diet, stressful situations, exercise, and symptoms can Crohn’s disease, malabsorption, celiac disease, food allergies, help to identify triggers. Parental guidance on alternative infectious processes, drug triggers, musculoskeletal pain, and prophylactic remedies should include lifestyle modificaupper gastrointestinal abnormalities (gastritis, esophagitis, tions, avoidance of ill-coping mechanisms to deal with gastroesophageal reflux, peptic ulcers), Helicobacter pylori, attacks, stress management, travel, sleeping habits, and gallbladder disease, kidney stones, urologic disorders, environmental factors, such as very bright or irideschronic pancreatitis, duodenal obstruction, sickle cell anecent/strobe lights, diet, and exercise. The STRESS mia crisis, gynecologic disorders (such as Mittelschmerz, mnemonic (Table 3) was developed by one of this articongenital uterine anomalies, recurrent ovarian cysts), poscle’s authors as an educational guide for providers and a terior fossa tumors, and seizure disorders if the child prespractical handout for parents. This guide was formulated ents with recurrent syncope or loss of consciousness.1,4,6 based on current literature and internet sources. Functional gastrointestinal disorders are conditions in which the child suffers from recurrent abdominal pain TREATMENT either as a neurobiological disorder, somatic response to Once underlying or acute processes have been ruled out 17 stress, or secondary gain. These disorders include funcand the diagnosis of AM has been established, therapeutic tional abdominal pain, chronic abdominal pain syndrome, approaches should include both pharmacological and irritable bowel syndrome, functional dyspepsia, chronic non-pharmacological measures. To date, limited research constipation, and aerophagia. The abdominal pain in AM is has been conducted in the treatment of AM in children. differentiated from chronic abdominal pain by the sporadic Current treatment modes for acute attacks focus on lessnature of the pain, location and duration, interference with ening symptoms and are based on anecdotal experience daily activities during the attack, and family history of with the disease, rather than evidence from clinical trials. migraine headaches.18 When acute abdominal pain with an The treatment goal of AM is to elicit prompt sympestablished diagnosis transforms to a chronic pattern, further tom relief and reintegration of the child to normality as investigation is warranted. soon as possible without furAM attacks can overlap ther setbacks. An effective therwith acute abdominal processes apeutic approach is adapted to and may be precipitated by the child and family based on The cornerstone of acute illnesses. For instance, the child’s symptomatology, treatment is preventing emesis accompanied by severe prior response to treatment, abdominal pain with or withand the family’s sociocultural recurrent attacks by out fever may indicate superhealth values, which may guide identifying and avoiding imposed disease process, such as their adherence to the treattrigger factors. appendicitis, Meckle’s diverticment recommended. An approulitis, bowel obstruction, volvupriate multidisciplinary team lus from malrotation, acute approach should include councholelithiasis, ureteropelvic junction obstruction, urolithiseling the parents and child while formulating a plan for asis, pyelonephritis, new onset diabetes mellitus in diaschool reintegration, along with referral for psychological betic ketoacidosis, and Munchausen syndrome by counseling if maladaptive coping mechanisms are 19 proxy. Any emesis accompanied by acute changes in present.19 Parental assurance, reassurance, and education neurological condition as evidenced by focal neurologic are vital components of the treatment. Russell and colfindings indicates increased intracranial pressure, seizures, leagues3 reported successful outcomes when parents were or metabolic disorder, requiring immediate action. assured that there was no severe abdominal pathology in the child. PREVENTION Parents of children diagnosed with AM should be Parents must be made aware that the cornerstone of reassured that complementary and alternative therapies treatment is preventing recurrent attacks by identifying during an acute pain exacerbation may help and should www.npjournal.org
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Table 3. STRESS Mnemonic for Prevention of Abdominal Migraine in Children S (Stress management)
Avoid stress and anxiety as much as possible Allow your child to have downtime during highly stressful situations
T (Travel tips)
Anticipate possible triggers related to travel such as motion sickness, altitude changes, disrupted sleep patterns, “wrong foods,” dehydration, and temperature fluctuations During travel, ensure that your child gets enough rest and maintains a regular sleep schedule, healthy diet, regular exercise, and consistent behavioral management
R (Rest)
Avoid irregular sleep patterns (either deprivation or excess sleep) Upon onset of the pain, provide a dark and quiet room for your child; sleep is the best treatment for a migraine attack
E (Emergency signs requiring medical attention)
Fever: either new onset or recurrent inexplicable fevers Unexplained weight loss or failure to grow Abdominal distress, such as vomiting bile, diarrhea, bloody stools, persistent pain between attacks Pain that wakens the child from sleep or radiation of pain to the back Mouth ulcers, difficulty swallowing
S (Sparkling lights)
Avoid prolonged exposure to strobes/flashing lights, bright flickering lights, such as the TV and computer screen
S (Snacks to avoid)
Foods containing caffeine (cola, chocolate, coffee, tea) Aged, overcooked, and processed meats; aged chesses, dried and canned fish Condiments: meat extracts, monosodium glutamate, soy sauce, vegemite, vinegar, Worstershire sauce Fruits: avocado, ripening banana, dates, kiwifruit, figs, grapes, lemon, lime, mandarin, orange, passion fruit, pineapple, plum, raspberry, tangerine Meats: any aged or frozen meat, bacon, beef liver, chicken liver, chicken skin, ham, pork, salami, sausage Snack foods: Brazil nuts, cheese or spicy-flavored snack foods, coconut, English mackernut, pecan, peanut, sesame seeds, sunflower seeds, walnut (black) Vegetables: broccoli, eggplant, sauerkraut, cauliflower, dill pickles, mushrooms, olives, spinach, tomato Fish: anchovies, fish marinades, fish meat, herring, mackerel, salami, salmon, dried sardines, canned tuna Dairy products: brie, cheddar, cracker barrel, Danish blue, gouda, mozzarella, Munster, parmesan, provolone, romano, Swiss
be tried before seeking pharmacologic treatment.1 In helping a child suffering from AM, providers can teach parents and children helpful coping strategies to deal with pain, such as relaxation techniques through deepbreathing and guided imagery to lessen stress. During an attack, the parent should allow the child to rest in a quiet, dark room until symptoms subside and reassure the child that this will be helpful. Table 4 outlines medications for AM in children. Over-the-counter analgesics and antiemetics often provide sufficient relief.1,18,20 If the pain escalates, prescription pharmacological treatment might be necessary. Limited data were found concerning appropriate prescription pharmacological management of AM attacks in children. Current pharmacological treatment is based 24
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on expert opinion and experience with medications used for migraine headaches, given the lack of wellcontrolled clinical trials.11 Additionally, data on the use of migraine headache drugs to treat abdominal migraines have been limited to children whose symptoms are not relieved by alternative therapies, when symptoms are severe and disabling. Anecdotal evidence reveals that AM attacks have been treated successfully in the pediatric population with triptans.18 Almotriptan, intranasal sumatriptan, and zolmitriptan are the most widely used drugs for migraine attacks and the only medications approved for acute attacks in adolescents.20 To date, almotriptan is the only medication approved by the Food and Drug Administration for the acute treatment of migraine in 12- to 17-year-olds,20,21 Volume 8, Issue 1, January 2012
Table 4. Medications for Management of Abdominal Migraine in Children Dosea
Medication Acute attacks Acetaminophen
15 mg/kg/dose every 4-6 hours as needed; max of 5 doses/day or 4gm/dayb
Ibuprofen
10 mg/kg/dose every 6-8 hours as needed; max of 40 mg/kg/day or 2.4 gm/dayb
Almotriptan
6.25-12.5 mg upon onset of migraine, may be repeated in 2 hours; max 25 mg/day (only for adolescents ⬎ 12 years)
Sumatriptan, intranasal
5-20 mg as soon as possible after the onset of pain, may repeat same dose after 2 hours; max 40 mg/dayb
Zolmitriptan, intranasal
2.5-5 mg as soon as possible after the onset of pain, may repeat same dose after 2 hours; max 10 mg/dayb
Prophylaxis (Based on anecdotal evidence rather than controlled trials) Amitriptylinec
1-1.5 mg/kg per day given before bedtime, max 300 mg/day
Propranololc
10 mg BID-TID
Cyproheptadinec
0.25-0.5 mg/kg/day divided TID
Valproic
acidc
Topiramatec
250-1000 mg divided BID 25-100 mg divided BID
aDose
based on literature recommendations23 bUse the lowest effective dose for the shortest period to reduce the risk of adverse reactions cInitiate treatment with lower dose; increase dose based on patient response
and intranasal sumatriptan and zolmitriptan have been approved by the European Medicines Agency (EMEA). Intranasal sumatriptan, one of the 7 available triptans studied in the United States, has been considered efficacious and safe for the acute treatment phase, based on the 2004 American Academy of Neurology management guidelines for acute migraine management in children.22 Nasal sumatriptan has been reported to be more effective than placebo in relieving headache, nausea, and vomiting during an acute migraine attack in the pediatric population20,21 and has been anecdotally used for AM attacks with similar success. The use of intranasal sumatriptan in children with AM is an off-label use and requires caution as serious adverse effects and death have been reported in children after its use.23 Adverse reactions to sumatriptan include acute cardiovascular effects, such as myocardial infarction, hypertension, life-threatening arrhythmias, stroke; gastrointestinal discomfort, such as nausea and vomiting; and neuromuscular and skeletal effects, such as weakness, myalgia, numbness, hyperreflexia, and meningismus.23 Lewis and colleagues24 examined the use of zolmitriptan nasal spray in 171 adolescents during a migraine attack. Intranasal zolmitriptan was well-tolerated and showed statistically significantly greater headache www.npjournal.org
relief and sustained resolution of associated migraine symptoms than placebo. The use of this spray for AM is also off-label, and its adverse effects are similar to those in intranasal sumatriptan. Tricyclic antidepressants, selective serotonin reuptake inhibitors, and anticholigernics are among the most common medications for AM prophylaxis.20, 21 The most common prophylactic medications in adolescents and adults reported in the literature are amitriptyline, propranolol, cyproheptadine, valproic acid, and topiramate.1,20,22 There are limited studies in children regarding prophylaxis therapy for AM. Until further studies are conducted and standardized criteria established, pharmacological prophylaxis treatment of AM in children should be deferred to pediatric neurologists. CONCLUSION The incidence and significance of AM in children is underappreciated, although the disease has been firmly established among headache authorities. Limited studies have been conducted on the management of AM in children, and recent findings advise the use of a multidisciplinary approach that includes pharmacologic and non-pharmacologic measures for prevention of AM in children and for treatment during AM exacerbations. Parental reassurance and education are critical components of treatment. The The Journal for Nurse Practitioners - JNP
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ultimate goal is to find the best treatment mode to reduce exacerbations, with the aim of improving the quality of life for children and their families. References 1. Cuvellier JC, Lepine A. Childhood periodic syndromes. Pediatr Neurol. 2010;42(1):1-11. 2. Mortimer MJ, Kay J, Jaron A. Clinical epidemiology of childhood abdominal migraine in an urban general practice. Develop Med Child Neurol. 1993;35(3):243-248. 3. Abu-Arafeh I, Russell G. Childhood Headache. Cambridge, MA: Cambridge University Press; 2002. 4. Bentley D, Kehely A, al-Bayaty M, Michie C. Abdominal migraine as a cause of vomiting in children: A clinician’s view. J Pediatr Gastroenterol Nutr. 1995;21(suppl 1):S49-51. 5. Headache Classification Subcommittee of the International Headache Society Classification and diagnostic criteria for headache disorders, cranial neuralgias, and facial pain. 2nd ed. Cephalgia. 2004;24(suppl 1):1-160. 6. Dooley JM, Pearlman EM. The clinical spectrum of migraine in children. Pediatr Ann. 2010;39(7):408-415. 7. Abend NS, Younkin D, Lewis DW. Secondary headaches in children and adolescents. Semin Pediatr Neurol. 2010;17(2):123-133. 8. Rasquin A, Di Lorenzo C, Forbes D, et al. Childhood functional gastrointestinal disorders: Child/adolescent. Gastroenterology. 2006;130(5):1527-1537. 9. Arruda MA, Guidetti V, Galli F, Albuquerque RC, Bigal ME. Childhood periodic syndromes: A population-based study. Pediatr Neurol. 2010;43(6):420-424. 10. Srinivasa R, Kumar R. Migraine variants and beyond. J Assoc Physicians India. 2010;58(suppl):14-17. 11. Popovich DM, Schentrup DM, McAlhany AL. Recognizing and diagnosing abdominal migraines. J Pediatr Health Care. 2010;24(6):372-377. 12. Brujin J, Locher H, Passchier J, Dijkstra N, Arts WF. Psychopathology in children and adolescents with migraine in clinical studies: A systematic review. Pediatrics. 2010;126(2):323-332. 13. Kabbouche MA, Cleves C. Evaluation and management of children and adolescents presenting with an acute setting. Semin Pediatr Neurol. 2010;17:105-108. 14. Ravishankar K. Migraine—The new understanding. J Assoc Physicians India. 2010;58(suppl):30-33. 15. Saps M, Li BU. Chronic abdominal pain of functional origin in children. Pediatr Ann. 2006;35(4):246-256. 16. Baber KF, Anderson J, Puzanovova M, Walker LS. J Pediatr Gastroenterol Nutr. 2008;47(3):299-302. 17. Li BU. Functional abdominal pain in children: New understanding, diagnostic criteria, and treatment approaches. Pediatr Ann. 2009;38(5):241-242. 18. Lewis DW, Pearlman E. The migraine variants. Pediatr Ann. 2005;34(6):486-497. 19. Ammoury RF, Pfefferkorn, MR, Croffie JM. Functional gastrointestinal disorders: Past and present. World J Pediatr. 2009;5(2):103-112. 20. Russell G, Abu-Arafeh I, Symon D. Abdominal migraine: evidence for existence and treatment options. Paediatr Drugs. 2002;4(1):1-8. 20. Papetti L, Spalice A, Nicita F, et al. Migraine treatment in developmental age: Guidelines update. J Headache Pain. 2010;11:267-276. 21. Hershey AD. Current approaches to the diagnosis and management of paediatric migraine. Lancet Neurology, 2010;9(2):190-204. 22. Eiland LS, Hunt MO. The use of triptans for pediatric migraines. Pediatr Drugs. 2010;12(6):379-389. 23. Taketomo CK, Hodding J H, Kraus DM. Pediatric Dosage Handbook. 17th ed. Hudson, OH: Lexi-Comp, Inc.; 2010. 24. Lewis DW, Winner P, Hershey AD, et al. Adolescent migraine steering committee. Efficacy of zolmitriptan nasal spray in adolescent migraine. Pediatrics. 2007;120:390-396. 1555-4155/12/$ see front matter © 2012 American College of Nurse Practitioners doi: 10.1016/j.nurpra.2011.06.007
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