What is abdominal migraine in children?

Even if you’ve never personally experienced a migraine before, you probably know the primary symptom is severe, debilitating head pain. While migraine can cause gastrointestinal (GI) issues such as nausea and vomiting, it is a neurological condition. It has nothing to do with your stomach, right? 

Yes and no. One of the many migraine variants is called abdominal migraine, where the person feels pain—along with other symptoms—in the abdominal region rather than the head. It’s more common in children, but can continue into adulthood—affecting young adults in particular with recurring pain, nausea, vomiting, and other migraine symptoms like fatigue and sensitivity to light or sound.

Though abdominal migraine symptoms appear primarily in your stomach, they don’t originate from there. Meaning, it’s still a brain-based condition. “We treat it like a migraine,” says Deborah I. Friedman, MD, a professor of neurology and ophthalmology at UT Southwestern Medical Center, “because the problem isn’t coming from your gut, it’s coming from your brain.”

Understandably, this condition can be tough to diagnose (especially in kids). Here’s a closer look at what abdominal migraine feels like, why it occurs, and how to treat it.

What is abdominal migraine? 

Healthcare providers are still trying to figure out exactly how or why the brain communicates with the gut during an episode of abdominal migraine. It seems like the same neurological trajectory as a traditional migraine is triggered, except for the fact that pain receptors in the abdomen—not the head—begin firing.

In fact, other than this one difference, an abdominal migraine attack is extremely similar to a common migraine attack; there is a surprising amount of overlap between symptoms, triggers, and treatment. The most common symptoms of abdominal migraine are abdominal pain, nausea, and vomiting. The abdominal pain is usually in the central abdomen and often described as soreness or achiness.

Abdominal migraine in adults vs. children

Abdominal migraine is far more common in children than adults, though experts still don’t know why. It may be that the underdeveloped nervous and gastrointestinal systems of young children leave them vulnerable to the biological processes that trigger an episode.

“It’s fairly common and pretty underdiagnosed,” says Lindsay Elton, MD, the medical director for child neurology at St. David’s North Austin Medical Center/St. David’s Children’s Hospital. “Families will come in and say they thought their kid was getting a lot of stomach bugs, but it was happening too regularly for that to make sense.” 

In the context of migraine conditions in children, Dr. Friedman estimates it occurs in about 2% to 4% of kids—which she says aligns with the overall prevalence of migraine in children.

Abdominal migraine often starts when kids are between 3 and 10 years old and is most common in children aged 7, per a 2018 abstract published in Pediatric Health, Medicine and Therapeutics.

But here’s where things get tricky: Although some kids outgrow abdominal migraine completely, Dr. Friedman estimates that about 70% go on to have traditional migraine episodes as they age and, less commonly, some will continue having abdominal migraine symptoms into adulthood.

“The older patients I’ve seen with it have all been young adults [who had abdominal migraine as a child],” she explains. “It may be brought up as a possible diagnosis in adults with episodes of abdominal pain, but I can’t think of any case where [abdominal migraine in an adult without prior history of it] was confirmed.”

In other words, many kids with abdominal migraine either outgrow the condition or experience a transition into traditional migraine episodes, but some continue having abdominal migraine even as they grow up. There’s no evidence that adults develop abdominal migraine out of the blue without having it in childhood.

Causes and risk factors

Unfortunately, experts don’t know the exact cause of abdominal migraine, but physicians have identified a few commonalities that may explain why some kids have it and others don’t.

In general, the triggers for abdominal migraine are the same as they are for traditional migraine: stress, anxiety, travel (or change in routine), lack of sleep or proper nutrition and hydration, and illness can all trigger an attack. Of course, age is usually a factor with this condition since it most often strikes in childhood; if your child fits the profile and is between 3 and 10, it’s more likely to be a possible cause of their symptoms.

Oddly enough for a condition that causes stomach pain, food isn’t typically considered a trigger. Dr. Friedman says dietary changes often don’t help much with preventing episodes, and Dr. Elton agrees, saying that parents of young kids may want to take a conservative approach to searching for possible food triggers.

“There are exhaustive food lists online [of potential triggers], but if you eliminated all those foods, there would be nothing left for your child to eat,” she warns, recommending that if you think something your child eats on a regular basis could be triggering attacks, try eliminating things slowly and one at a time rather than making sweeping changes.

As far as risk factors, there’s mainly only one: genetics. “There is a significant hereditary component in migraine,” says Dr. Elton. “We often find a positive family history of migraine in other family members, [particularly] in a child’s siblings.”

Symptoms of abdominal migraine 

Clearly, abdominal pain is a common symptom of this type of migraine; the pain may be moderate to severe and might feel like an aching or dull throbbing in the center of the abdomen near the belly button. But abdominal pain isn’t the only symptom. Others include:

• Nausea
• Vomiting
• Loss of appetite
• Pallor
• Fatigue
• Other common migraine symptoms such as sensitivity to light, smells, or sound, or even aura (although aura isn’t as common as most people believe in even traditional migraine)

Episodes usually last about 72 hours, which encompasses the average length of a typical migraine when you factor in prodrome and postdrome symptoms.

For the most part, abdominal migraine isn’t serious or dangerous. Unless your child can’t keep anything down, appears dehydrated, weak, or lethargic, or shows any other signs of distress such as shortness of breath, you should be able to manage your child’s migraine at home.

The biggest danger of abdominal migraine is the fact that its symptoms closely mimic several other more severe conditions—so ignoring persistent symptoms without knowing for sure that migraine is to blame could lead to serious illness.

“More dangerous than the migraine itself is the potential that we would attribute the symptoms to migraine when it could be something else [such as appendicitis],” Dr. Elton says. Other conditions that share a symptom profile with abdominal migraine are common GI conditions such as Crohn’s disease, stomach ulcers, renal conditions, and even epilepsy, which Dr. Friedman notes can cause nausea and vomiting.

Diagnosis of abdominal migraine 

A diagnosis of abdominal migraine is what Dr. Elton calls a diagnosis of exclusion. Meaning, you can’t definitively diagnose someone with it because there are no tests to confirm it exists. But, you can rule out other conditions that cause similar symptoms and, ultimately, end up at an abdominal migraine diagnosis if everything else seems in order. 

The provider can start with a comprehensive medical history and physical examination; it is particularly important they ask about family history of migraine or headaches. Many times, you do not need a specialist to diagnose abdominal migraine. If the provider performs a physical examination for your child, runs blood panels or other diagnostic tests, and can’t find any sign of GI disease, irritable bowel syndrome (IBS), ulcers or obstructions, reflux, or gallbladder issues, that’s a good sign that the problem may not be with the gut but with the brain. At that point, your child may be referred to a neurologist.

But don’t jump the gun: Dr. Elton says a primary care provider or pediatrician is the best first step to take before seeing a specialist. They can rule out acute viral infection, ask you about your family history of migraine or GI illness, and decide where to refer you next, if need be. 

It can be tricky to diagnose abdominal migraine, but the diagnostic criteria includes the following: 

• The child has at least five attacks of abdominal pain, and include:
  • Pain has at least two of the following three characteristics:

1. 1. 1. Is in the midline location, behind the belly button
      2. Is dull or has a “just sore” quality
      3. Is moderate or severe intensity

• • At least two of the following four associated symptoms or signs:
    1. Anorexia
    2. Nausea
    3. Vomiting
    4. Pallor
  • Attacks that last two to 72 hours when untreated or unsuccessfully treated

• The child has no symptoms between attacks
• The symptoms are not attributed to another disorder

Treatment options and prevention 

For young and older adults with continuing abdominal migraine, the treatment plan is essentially the same as it is for traditional migraine. You may need a combination of preventive and rescue migraine medications to manage attacks of abdominal pain depending on the severity and frequency of your episodes.

You can also make some lifestyle changes to prevent migraine attacks or at least reduce the frequency of them, including:

• Managing your stress and anxiety
• Eating a nutritious diet
• Exercising regularly
• Staying hydrated
• Getting enough restorative sleep

Some people also find therapeutic strategies like acupuncture, meditation, and vitamin supplementation to be useful additions to their migraine treatment arsenal.

While younger children can benefit from many of these lifestyle changes to treat and prevent migraine, unfortunately there are not as many pharmaceutical options recommended for pediatric use.

“Nothing is approved for use in kids and most of what we use is off-label,” says Dr. Elton. “That’s not to say that these medications are safe, but they don’t carry an FDA label for approved use in children.”

That means pediatric providers like Dr. Elton have to get creative with acute treatments. Many medications have a long history of safe use in children, she says, but lack evidence specifically for treating abdominal migraine. For example, for infrequent episodes, a child might benefit from treatment with anti-nausea drugs or certain triptans; for more chronic episodes, some antidepressants and antihistamines are safe and generally well-tolerated in young children.