Abdominal Migraine and Cyclic Vomiting Syndrome

 

Image 1: http://assets.gastrodigestivesystem.com/stomach/cyclic-vomiting-syndrome... Accessed 9/18/15.

Introduction

An abdominal migraine is a disorder primarily of children and presents as episodes of abdominal pain, usually without accompanying headache. Cyclic vomiting syndrome is characterized by severe, repeated attacks of nausea and vomiting with no apparent cause. 

Abdominal Migraine (AM) and Cyclic Vomiting Syndrome (CVS) are suitably considered together, as they have the following important features in common:

1: Predominance in children

2: Diagnosis of exclusion

3: Emerging acceptance and understanding of the diagnosis

4: Association with migraine headaches

For both disorders an understanding of the underlying pathophysiology is currently lacking, but their considerable prevalence and consistent symptomatology necessitate diagnostic classification.

Epidemiology

AM is estimated to occur in 1%-4% of children, most commonly in adolescent girls. CVS is less common, although some studies estimate as high as a 2% prevalence in children.

Both disorders have a strong association with migraine headache. As many as 80% of children with CVS also have migraines. Several epidemiological studies of AM have found the rates of both personal and family history of migraine headaches to be well above 50%, and sometimes as high as 90%.

Presentation and Diagnosis

AM is characterized by episodes of midline, periumbilical, or poorly localized abdominal pain lasting from 1 to 72 hours, with intervening periods of normalcy. The pain is usually moderate to severe and described as “dull” or “sore.” Patients often experience anorexia, nausea, vomiting, or pallor concurrent with the pain. It is crucial for diagnosis that the patient has had several episodes of this pain, and that the history, physical exam, laboratory values, and additional studies have all been negative for any gastrointestinal or renal etiologies.

CVS is characterized by repeated episodes of severe nausea and vomiting that typically last anywhere from a few hours to several days.  The nature of these episodes is highly variable between patients and there are many causes of vomiting, which can make diagnosis difficult.  However, certain features are characteristic of CVS and raise suspicion for it in the absence of other etiologies:

• Multiple episodes with intervening periods of normalcy
• Three or more discrete episodes in the prior year
• Patient’s episodes are stereotypical with regard to onset (acute), duration (hours to days), and symptomatology

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The diagnosing physician should always ask about a personal or family history of migraine, as this significantly raises suspicion for these two disorders and may aid in the diagnosis.

Treatment

Once AM or CVS has been correctly diagnosed, treatment for both disorders is very similar to that of migraine headaches.

Between attacks:

• Identification and avoidance of “triggers,” which may be dietary, environmental, or psychosocial
• Emphasis on adequate and regular sleep, adequate fluid and nutritional intake, and stress reduction
• If attacks frequent and severe: Consider migraine prophylaxis medications such as amitriptyline, propranolol, cyproheptadine, coenzyme Q10, or L-carnitine

During attacks:

• Quiet, dark room for the patient
• Analgesics such as ibuprofen or acetaminophen
• Antiemetics such as ondansetron
• Triptans
• IV fluids if necessary

Treatment is specific to the individual patient, what works for him/her, and what has worked in the past.

Prognosis

There is no cure for AM or CVS. That said, the outlook for patients is generally quite favorable. This is because the natural history of these disorders is such that, many children outgrow AM or CVS by adolescence. Though AM and CVS can be diagnosed in adults, it is much rarer in this population. Careful attention to diet, habits, triggers, and prophylaxis is often successful in reducing the frequency of attacks. Many treatments are available to reduce the length and severity of attacks. Of note, it is common for AM and CVS patients to develop migraine headaches as an adult.

Childhood Periodic Syndromes

In recent years, significant discussion has centered on the idea that AM and CVS are just two of several childhood disorders, the “childhood periodic syndromes” (CPS) that share a common underlying etiology with adult migraine. Other suggested CPS disorders include benign paroxysmal torticollis, benign paroxysmal vertigo, and, perhaps most interestingly, infantile colic.

References

1. Evans RW, Whyte C. Cyclic vomiting syndrome and abdominal migraine in adults and children. Headache. 2013 Jun;53(6):984-93.
2. Gelfand AA. Migraine and childhood periodic syndromes in children and adolescents. Curr Opin Neurol. 2013 Jun;26(3):262-8
3. Lagman-Bartolome AM, Lay C. Pediatric migraine variants: a review of epidemiology, diagnosis, treatment, and outcome. Curr Neurol Neurosci Rep. 2015 Jun;15(6):34.
4. Popovich DM, Schentrup DM, McAlhany AL. Recognizing and diagnosing abdominal migraines. J Pediatr Health Care. 2010 Nov-Dec;24(6):372-7.
5. Russell G, Abu-Arafeh I, Symon D. Abdominal migraine: evidence for existence and treatment options. Pediatric Drugs. 2002; 4(1):1-8.
6. Teixeira KC, Montenegro MA, Guerreiro MM. Migraine equivalents in childhood. J Child Neurol. 2014 Oct;29(10): 1366-9
7. Image 1: http://assets.gastrodigestivesystem.com/stomach/cyclic-vomiting-syndrome... Accessed 9/18/15.
8. Image 2: http://www.buzzle.com/img/articleImages/286819-1011-13.jpg Accessed 9/18/15.
9. Lagman-Bartolome AM, Lay C. Pediatric migraine variants: a review of epidemiology, diagnosis, treatment, and outcome. Curr Neurol Neurosci Rep. 2015 Jun;15(6):34.