Prevalence and clinical features of abdominal migraine compared with those of migraine headache

WITHDRAWN: Psychosocial interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood

This Review is being updated and replaced following the publication of a new Protocol (Martin AE, Newlove‐Delgado TV, Abbott RA, Bethel A, Thompson‐Coon J, Nikolaou v, Logan S. Psychosocial interventions for recurrent abdominal pain in childhood (Protocol). Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD010971. DOI: 10.1002/14651858.CD010971). It will remain withdrawn when the new Review is published.

The editorial group responsible for this previously published document have withdrawn it from publication.

Migraine-related symptoms in childhood

Periodic disorders of childhood often represent precursors of migraine. As we advance our knowledge of migraine and its complicated phenotypic presentation in childhood, we have noted the similarities in overlapping symptoms of children presenting with childhood periodic syndromes. There is often a positive family history of migraine in children that present with periodic syndromes. There is a known transformation of periodic syndromes from childhood into adult migraine with and without aura phenotype. There has been an evolution of our understanding of what was initially referred to as periodic symptoms of childhood and more recently been called childhood periodic syndromes and is now evolving into the terminology of episodic symptoms that are associated with migraine. International classification of headache disorders has been instrumental in the evolution of the classification of headache and children adults. The most recent classification utilizes and replaces the periodic symptom terminology with episodic symptoms that will no longer be limited to just childhood. This article will address the evolution of our understanding of the diagnostic criteria, pathophysiology and management of the episodic syndromes that may be associated with migraine.

Age-related prevalence and features of migraine headache in Hungarian schoolchildren and adolescents

BACKGROUND

Differences occur in certain features of childhood and adult migraine, such as the duration and location. However, few studies have been reported of the changes in other symptoms during childhood.

AIMS

The aims of this study were to establish the prevalence of migraine headache in children in Hungary, and to investigate the changes in prevalence of migraine and migraine symptoms in a wide paediatric age range.

METHODS

We conducted a school-based study with the use of a questionnaire.

RESULTS

7361 7-18-year-old students participated. The 1-year prevalence of migraine was 12.5% (9.2% in boys and 15.4% in girls). With the criterion of a headache duration of 4 h for 15-18-year-olds and of 1 h below the age of 15, the overall prevalence decreased to 9.1%. The prevalence of migraine increased steadily from young childhood to late adolescence in both boys and girls. The frequency and duration of headache increased, whereas vomiting and nausea became less prevalent with advancing age in both genders. The prevalence of uni/bilaterality, photophobia and phonophobia increased only in girls, while that of a pulsating character did so only in boys.

CONCLUSIONS

The migraine characteristics displayed by the studied population proved similar to those experienced in other countries. The duration of headache applied in the diagnosis of migraine exerts a great impact on the prevalence data. The features of migraine change with advancing age, a situation demanding consideration in studies on migraine in children of different ages.

Intravenous dihydroergotamine therapy for pediatric abdominal migraines

Abdominal migraines present with debilitating symptoms in adolescence. At our institution, the gastroenterology, neurology, and autonomic departments collaborated in treating patients with such presentations. This case series describes 6 patients who were given intravenous dihydroergotamine (DHE) for presumed abdominal migraines. DHE was only used when other agents like amitriptyline, verapamil, topiramate, or depakote had proved ineffective. DHE was started at 0.5 mg dose and on average 7 to 9 mg were given on each hospitalization. Patient ages ranged from 13 to 19 years with the majority being female. One patient did not respond to treatment. One patient was admitted 4 times for symptoms of abdominal migraines resolving with DHE. The average time between symptom relapse was about 5 to 12 months. Five of our 6 patients responded to the infusion without significant side effects. Based on these case series, DHE may be a treatment option in children with intractable abdominal migraine.

Migraine variants--occurrence in pediatric neurology practice

Migraine is common in pediatric neurology practice, while migraine variants are rare and pose diagnostic problems.

OBJECTIVE

The aim was to establish the occurrence of migraine variants in pediatric neurology practice and among migraine, and to discuss their presentation.

PATIENTS AND METHODS

The files of 2509 newly diagnosed patients, aged 0-18 years, treated as in- and out-patients in the Neuropediatric Ward at the Plovdiv Medical University Hospital between 2002 and 2006 were examined retrospectively. Migraine forms were diagnosed according to ICHD-II. Benign paroxysmal torticolis and alternating hemiplegia of childhood were also accepted as migraine variants according to proposed diagnostic criteria in the appendix of ICHD-II. Some specific forms like acute confusional migraine (ACM), Alice in wonderland syndrome (AWS), ophthalmoplegic migraine were also diagnosed although not included as migraine variants in the ICHD-II classification.

RESULTS

111 patients met diagnostic criteria for migraine. Patients with migraine variants comprised 24.3% of migrainous cases. Basilar type migraine was the most common (6.3% of all migrainous patients), followed by benign paroxysmal vertigo (5.4%), hemiplegic migraine (3.6%), ACM (2.7%), benign paroxysmal torticolis (2.7%), typical aura without headache (1.8%), abdominal migraine (1.8%), AWS (0.9%), ophthalmoplegic migraine (0.9%) and cyclical vomiting (0.9%). Alternating hemiplegia of childhood and retinal migraine was not found. Some patients either presented or were classified as different migraine variants.

CONCLUSION

Basilar type migraine was the most common migraine variant. ACM and AWS should be regarded as distinct entities in the ICHD as migraine with complex aura. Benign paroxysmal torticollis also deserves its place as a migraine variant. Cases of ophthalmoplegic migraine with spontaneous remission and no cranial nerve enhancement on MRI should be considered as migraine form. Analyzing migraine variants will contribute to better awareness and adequate diagnosis.

Abdominal migraine, another cause of abdominal pain in adults

BACKGROUND

Abdominal migraine is a diagnostically challenging childhood disorder, characterized by recurrent episodes of abdominal pain, which has not been clearly demonstrated to occur in adults.

METHODS

We used 2 sets of consensus criteria for the diagnosis of abdominal migraine in children to evaluate adults suspected of having this condition in both our own patient population and in the medical literature. Two patients in our clinic and 11 patients from the medical literature composed our initial study cohort and were analyzed using the International Classification of Headache Disorders, 2(nd) Edition and American College of Gastroenterology Rome III Diagnostic Criteria for abdominal migraine in children.

RESULTS

Ten of these patients met inclusion criteria for definite or probable abdominal migraine and comprised our final study cohort. The 10 patients from this adult cohort shared common demographic and clinical characteristics with children suffering from abdominal migraine, including a familial history of migraine in 90%.

CONCLUSIONS

Our findings demonstrate that abdominal migraine occurs and should be considered in the differential diagnosis of recurrent abdominal pain in adults, especially if there is a family history of migraine headaches.

Abdominal migraine reviewed from both central and peripheral aspects

Despite the 2%-5% prevalence of abdominal migraine (AM) during childhood, the precise mechanism remains unknown. In this review, we present recent studies on AM and speculate its mechanism from both peripheral and central nervous system aspects. Although the main symptoms of AM exist at the peripheral level, previous studies have reported possible dysfunction of central nervous system, including photophobia, phonophobia and abnormal visual evoked responses. Recently, a case has been reported with AM combined with “Alice in Wonderland” syndrome with visual and/or bodily distortions, which serves as another piece of evidence of central dysfunction. Another case reported an AM patient having peculiar stereotypical ecchymosis in the legs and buttocks associated with pain attack, which implied possible involvement of peripheral nervous system. Although further investigations and accumulation of AM cases are still needed, we believe that the schema hypothesized here is helpful to plan further experimental approach to clarify the mechanism of this peculiar disease.

Self-reported muscle pain in adolescents with migraine and tension-type headache

AIM

To identify possible associations between muscular pain and headache in adolescents in a large population-based sample.

METHODS

Grammar school students were invited to fill in a questionnaire on headache and associated lifestyle factors. Headache was classified according to the German version of the International Classification of Headache Disorders (2nd edition). Muscular pain was assessed via denoting affected areas in schematic drawings of a body and via provoked muscular pain on controlled movements of head, neck and shoulder regions.

RESULTS

Prevalence of any headache within the previous 6 months exceeded 80%. In all subjects muscular pain or pain on movement was most prominent in the neck and shoulder region, ranging from 9% to 27% in the non-headache population to up to 63% for individuals with migraine or mixed migraine and tension-type headache (TTH). Frequency of muscular pain increased significantly with growing chronicity of TTH.

INTERPRETATION

A strong association between muscle pain in the neck/shoulder region and headache was observed, pointing to the importance of muscular pain for headache in adolescents. Also, in this age group muscular pain appears to be of particular importance in chronic TTH and - unexpectedly - in migraine, which is the most important new finding in our study.

Abdominal pain-predominant functional gastrointestinal diseases in children and adolescents: prevalence, symptomatology, and association with emotional stress

BACKGROUND AND OBJECTIVE

Functional gastrointestinal disorders (FGD) are common among children, but little is known regarding their prevalence in developing countries. We assessed the prevalence of abdominal pain-predominant FGD, in addition to the predisposing factors and symptomatology, in Sri Lankan children.

PATIENTS AND METHODS

A cross-sectional survey was conducted among a randomly selected group of 10- to 16-year-olds in 8 randomly selected schools in 4 provinces in Sri Lanka. A validated, self-administered questionnaire was completed by children independently in an examination setting. FGD were diagnosed using Rome III criteria.

RESULTS

A total of 2180 questionnaires were distributed and 2163 (99.2%) were included in the analysis (1189 [55%] boys, mean age 13.4 years, standard deviation 1.8 years). Of them, 270 (12.5%) had at least 1 abdominal pain-predominant FGD. Irritable bowel syndrome (IBS) was seen in 107 (4.9%), functional dyspepsia in 54 (2.5%), functional abdominal pain in 96 (4.4%), and abdominal migraine (AM) in 21 (1.0%) (2 had AM and functional dyspepsia, 6 had AM and IBS). Extraintestinal symptoms were more common among affected children (P < 0.05). Abdominal pain-predominant FGD were higher in girls and those exposed to stressful events (P < 0.05). Prevalence negatively correlated with age (r = -0.05, P = 0.02).

CONCLUSIONS

Abdominal pain-predominant FGD affects 12.5% of children ages 10 to 16 years and constitutes a significant health problem in Sri Lanka. IBS is the most common FGD subtype present. Abdominal pain-predominant FGD are higher in girls and those exposed to emotional stress. Prevalence of FGD decreased with age. Extraintestinal symptoms are more frequent in affected children.

[Childhood periodic syndromes]

This review focuses on the so-called "periodic syndromes of childhood that are precursors to migraine", as included in the Second Edition of the International Classification of Headache Disorders. Three periodic syndromes of childhood are included in the Second Edition of the International Classification of Headache Disorders: abdominal migraine, cyclic vomiting syndrome and benign paroxysmal vertigo, and a fourth, benign paroxysmal torticollis is presented in the Appendix. The key clinical features of this group of disorders are the episodic pattern and intervals of complete health. Episodes of benign paroxysmal torticollis begin between 2 and 8 months of age. Attacks are characterized by an abnormal inclination and/or rotation of the head to one side, due to cervical dystonia. They usually resolve by 5 years. Benign paroxysmal vertigo presents as sudden attacks of vertigo, accompanied by inability to stand without support, and lasting seconds to minutes. Age at onset is between 2 and 4 years, and the symptoms disappear by the age of 5. Cyclic vomiting syndrome is characterized in young infants and children by repeated stereotyped episodes of pernicious vomiting, at times to the point of dehydration, and impacting quality of life. Mean age of onset is 5 years. Abdominal migraine remains a controversial issue and presents in childhood with repeated stereotyped episodes of unexplained abdominal pain, nausea and vomiting occurring in the absence of headache. Mean age of onset is 7 years. Both cyclic vomiting syndrome and abdominal migraine are noted for the absence of pathognomonic clinical features but also for the large number of other conditions to be considered in their differential diagnoses. Diagnostic criteria, such as those of the Second Edition of the International Classification of Headache Disorders and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, have made diagnostic approach and management easier. Their diagnosis is entertained after exhaustive evaluations have proved unrevealing. The recommended diagnostic approach uses a strategy of targeted testing, which may include gastrointestinal and metabolic evaluations. Therapeutic recommendations include reassurance, both of the child and parents, lifestyle changes, prophylactic therapy (e.g., cyproheptadine in children 5 years or younger and amitriptyline for those older than 5 years), and acute therapy (e.g., triptans, as abortive therapy, and 10% glucose and ondansetron for those requiring intravenous hydration).

Childhood periodic syndromes

This review focuses on so-called "periodic syndromes of childhood that are precursors to migraine," as included in the second edition of the International Classification of Headache Disorders. Presentation is characterized by an episodic pattern and intervals of complete health. Benign paroxysmal torticollis is characterized by recurrent episodes of head tilt, secondary to cervical dystonia, with onset between ages 2-8 months. Benign paroxysmal vertigo presents as sudden attacks of vertigo lasting seconds to minutes, accompanied by an inability to stand without support, between ages 2-4 years. Cyclic vomiting syndrome is distinguished by its unique intensity of vomiting, affecting quality of life, whereas abdominal migraine presents as episodic abdominal pain occurring in the absence of headache. Their mean ages of onset are 5 and 7 years, respectively. Diagnostic criteria and appropriate evaluation represent the key issues. Therapeutic recommendations include reassurance, lifestyle changes, and prophylactic as well as acute antimigraine therapy.

Diagnosing pediatric functional abdominal pain in children (4-15 years old) according to the Rome III Criteria: results from a Norwegian prospective study

OBJECTIVES

To determine the proportion of referred children with nonorganic abdominal pain who meet the criteria for 1 or more diagnoses of functional gastrointestinal disorders (FGID), explore the distribution of diagnoses according to the revised pediatric Rome III criteria (PRC-III), and to investigate reasons for failure to meet these criteria.

MATERIALS AND METHODS

We recruited children (4-15 years) consecutively referred by general practitioners to 4 general pediatric outpatient clinics for the evaluation of recurrent abdominal pain. FGID diagnoses were based on the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III version, completed by parents. To exclude organic disease, all patients underwent medical investigations and were reevaluated at follow-up after 6 to 9 months.

RESULTS

Of the 152 patients included, 142 (93%) had functional abdominal pain. Of these, 124 (87%) met the criteria for 1 or more diagnoses according to the PRC-III: 66% met the criteria for 1, 29% for 2, and 5% for 3 diagnoses. Irritable bowel syndrome was the most common diagnosis (43%) and overlapped with aerophagia in 16 children (38% of the children with overlapping diagnoses) and with abdominal migraine in 14 (33%). In the 18 patients (13%) not fulfilling the PRC-III for any FGID diagnosis, the main reason was insufficient pain frequency (83%).

CONCLUSIONS

Of the referred children with functional abdominal pain, 87% met the PRC-III for specific diagnoses. This supports the use of these criteria as a diagnostic tool. The significant overlap between different FGIDs, however, makes it unclear whether some of the diagnoses represent distinct disorders or artificial categories.

Dietary interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood

BACKGROUND

Between 4% and 25% of school-age children complain of recurrent abdominal pain (RAP) of sufficient severity to interfere with daily activities. It is unclear whether the diagnosis includes children with different aetiologies for their pain. For the majority no organic cause for their pain can be found on physical examination or investigation. Although most children are likely managed by reassurance and simple measures, a large range of interventions have been recommended.

OBJECTIVES

To determine the effectiveness of dietary interventions for recurrent abdominal pain in school-age children.

SEARCH STRATEGY

The Cochrane Library (CENTRAL) 2006 (Issue 4), MEDLINE (1966 to Dec 2006), EMBASE (1980 to Dec 2006), CINAHL (1982 to Dec 2007), ERIC (1966 to Dec 2006), PsycINFO (1872 to Dec 2006), LILACS (1982 to Dec 2006), SIGLE (1980 to March 2005), and JICST (1985 to 06/2000) were searched . Where appropriate, search filters were employed. Researchers working in this area were asked to identify relevant studies.

SELECTION CRITERIA

Randomised or quasi-randomised studies of any dietary treatment versus placebo or no treatment in school-age children with a diagnosis of RAP or functional gastrointestinal disorder based on the Rome II criteria.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trials for inclusion, assessed quality and extracted data. Where appropriate studies were pooled using a random effects meta-analysis.

MAIN RESULTS

Seven trials were included in this review. Two trials, including 83 participants, compared fibre supplements with placebo (Christensen 1982, Feldman 1985), with data from one study reported in two papers (Christensen 1982, Christensen 1986). The pooled odds ratio for improvement in the frequency of abdominal pain was 1.26 (0.25, 6.29). Two trials, including 90 participants (Lebenthal 1981, Dearlove 1983) compared lactose-containing with lactose-free diets. Neither reported data in a form which could be used in the meta-analysis and the former trial had a loss to follow-up of 45%. We were not able to obtain further data for either trial. Three trials (Bausserman 2005, Gavronska 2007, Young 1997) comparing supplementation with Lactobacillus with placebo met the inclusion criteria but only two (Bausserman 2005, Gavronska 2007), including a total of 168 children, provided analysable data. The pooled odds ratio for improvement of symptoms was 1.17 (95% CI 0.62, 2.21).

AUTHORS' CONCLUSIONS

There is a lack of high quality evidence on the effectiveness of dietary interventions. This review provides no evidence that fibre supplements, lactose free diets or lactobacillus supplementation are effective in the management of children with RAP.

Management of pediatric migraine: Current concepts and controversies

Migraine in children and adolescents is a common condition. Emerging knowledge about the pathophysiology of migraine is leading to new targeted treatments toward specific mechanisms of migraine. This review explores the evidence for different treatments for pediatric migraine including the periodic syndromes of childhood that commonly represent precursors to migraine.

Pain Catastrophizing Scale for Francophone Adolescents: a preliminary validation

BACKGROUND

In adults, it is well known that high levels of pain catastrophizing are related to increased pain and disability as well as to heightened anxiety and depression. However, due to the lack of a measure of pain catastrophizing adapted for francophone adolescents, little is known about the role of catastrophizing in this population.

OBJECTIVES

To adapt the French version of the Pain Catastrophizing Scale (PCS) and to examine the psychometric properties and factorial structure of the PCS for Francophone Adolescents (PCS-Ado).

METHODS

The French version of the PCS was modified by a group of experts. The format of the questions was modified to be appropriate for adolescents aged between 12 and 18 years. To assess the psychometric properties of the PCS-Ado, 345 adolescents completed the PCS-Ado and questionnaires measuring depression, anxiety and intensity of pain. Twelve to 16 weeks later, participants completed the questionnaires again to examine the test-retest reliability of the PCS-Ado.

RESULTS

Results revealed a three-factor solution similar to the original PCS. In addition, results revealed that PCS-Ado had good internal consistency (PCS-Ado total: 0.85; rumination: 0.72; magnification: 0.66; helplessness: 0.74), and high test-retest reliability (r=0.73). Finally, significant correlations among catastrophizing, depression, anxiety and pain intensity support the construct validity of the PCS-Ado.

CONCLUSIONS

The results suggest that the PCS-Ado is valid and reliable with francophone adolescents. Further research is required to assess the validity of the PCS-Ado in clinical settings.

Pharmacological interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood

BACKGROUND

Between 4% and 25% of school-age children complain of recurrent abdominal pain (RAP) of sufficient severity to interfere with daily activities. For the majority no organic cause for their pain can be found on physical examination or investigation and although most children are likely managed by reassurance and simple measures, a large range of interventions have been recommended.

OBJECTIVES

To determine the effectiveness of medication for recurrent abdominal pain in school-age children.

SEARCH STRATEGY

The Cochrane Library (CENTRAL) 2006 (Issue 4), MEDLINE (1966 to Dec 2006), EMBASE (1980 to Dec 2006), CINAHL (1982 to Dec 2007), ERIC (1966 to Dec 2006), PsycINFO (1872 to Dec 2006), LILACS (1982 to Dec 2006), SIGLE (1980 to March 2005), and JICST (1985 to 06/2000) were searched with appropriate filters

SELECTION CRITERIA

Studies on school age children with RAP (Apley or the Rome II criteria for gastrointestinal diseases) allocated by random or quasi-random methods to a drug treatment vs. placebo/ no treatment were included.

DATA COLLECTION AND ANALYSIS

References identified by the searches were screened against the inclusion criteria by two independent reviewers. Data was extracted and analysed using RevMan 4.2.10.

MAIN RESULTS

Three trials met the inclusion criteria. Symon et al report a cross-over trial comparing pizotifen and placebo in 16 children with "abdominal migraine". Data before cross-over was not available. Results for 14 children showed Mean fewer days in pain of 8.21 (95% CI 2.93, 13.48) while taking the active drug. Kline et al compared peppermint oil capsules with placebo in a randomised trial in 50 children with RAP and IBS. 42 children completed the study. OR for improvement was 3.33 (95% CI 0.93-12.1)See et al compared famotidine with placebo in a randomised cross-over trial in 25 children with RAP and dyspepsia. OR for improvement before cross-over was 11 (95%CI 1.6, 75.5).

AUTHORS' CONCLUSIONS

This review provides weak evidence of benefit on medication in children with RAP. The lack of clear evidence of effectiveness for any of the recommended drugs suggests that there is little reason for their use outside of clinical trials. Clinicians may choose to prescribe drugs in children with severe symptoms that have not responded to simple management. However, if using drugs as a "therapeutic trial", clinicians should be aware that, RAP is a fluctuating condition and any "response" may reflect the natural history of the condition or a placebo effect rather than drug efficacy.

Dietary interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood

BACKGROUND

Between 4% and 25% of school-age children complain of recurrent abdominal pain (RAP) of sufficient severity to interfere with daily activities. It is unclear whether the diagnosis includes children with different aetiologies for their pain. For the majority no organic cause for their pain can be found on physical examination or investigation. Although most children are likely managed by reassurance and simple measures, a large range of interventions have been recommended.

OBJECTIVES

To determine the effectiveness of dietary interventions for recurrent abdominal pain in school-age children.

SEARCH STRATEGY

The Cochrane Library (CENTRAL) 2006 (Issue 4), MEDLINE (1966 to Dec 2006), EMBASE (1980 to Dec 2006), CINAHL (1982 to Dec 2007), ERIC (1966 to Dec 2006), PsycINFO (1872 to Dec 2006), LILACS (1982 to Dec 2006), SIGLE (1980 to March 2005), and JICST (1985 to 06/2000) were searched . Where appropriate, search filters were employed. In addition, researchers working in this area were asked to identify relevant studies.

SELECTION CRITERIA

Randomised or quasi-randomised studies of any dietary treatment versus placebo or no treatment in school-age children with a diagnosis of RAP or functional gastrointestinal disorder based on the Rome II criteria.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trials for inclusion, assessed quality and extracted data. Where appropriate studies were pooled using a random effects meta-analysis.

MAIN RESULTS

Seven trials were included in this review. Two trials, including 83 participants, compared fibre supplements with placebo (Christensen 1982, Feldman 1985), with data from one study reported in two papers (Christensen 1982, Christensen 1986). The pooled odds ratio for improvement in the frequency of abdominal pain was 1.16 (95% CI 0.45-2.87). Two trials, including 90 participants (Lebenthal 1981, Dearlove 1983) compared lactose-containing with lactose-free diets. Neither reported data in a form which could be used in the meta-analysis and the former trial had a loss to follow-up of 45%. We were not able to obtain further data for either trial. Three trials (Bausserman 2005, Gavronska 2007, Young 1997) comparing supplementation with Lactobacillus with placebo met the inclusion criteria but only two (Bausserman 2005, Gavronska 2007), including a total of 168 children, provided analysable data. The pooled odds ratio for improvement of symptoms was 1.17 (95% CI 0.62, 2.21).

AUTHORS' CONCLUSIONS

There is a lack of high quality evidence on the effectiveness of dietary interventions. This review provides no evidence that fibre supplements, lactose free diets or lactobacillus supplementation are effective in the management of children with RAP.

Psychosocial interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood

BACKGROUND

Between 4% and 25% of school-age children complain of recurrent abdominal pain (RAP) of sufficient severity to interfere with daily activities. For the majority of such children, no organic cause for their pain can be found on physical examination or investigation. Although most children are managed by reassurance and simple measures, a large range of psychosocial interventions including cognitive and behavioural treatments and family therapy have been recommended.

OBJECTIVES

To determine the effectiveness of psychosocial interventions for recurrent abdominal pain or IBS in school-age children.

SEARCH STRATEGY

The Cochrane Library (CENTRAL) 2006 (Issue 4), MEDLINE (1966 to Dec 2006), EMBASE (1980 to Dec 2006), CINAHL (1982 to Dec 2006), ERIC (1966 to Dec 2006), PsycINFO (1872 to Dec 2006), LILACS (1982 to Dec 2006), SIGLE (1980 to March 2005), and JICST (1985 to 06/2000) were searched with appropriate filters.

SELECTION CRITERIA

Any study in which the majority of participants were school-age children fulfilling standard criteria for RAP (Apley or the Rome II criteria for functional gastrointestinal diseases) , randomly allocated to any psychosocial treatment compared to standard care or waiting list, were selected.

DATA COLLECTION AND ANALYSIS

References identified by the searches were independently screened against the inclusion criteria by two reviewers. Data were extracted and analysed using RevMan 4.2.10.

MAIN RESULTS

Six randomised trials (including a total of 167 participants) of cognitive behavioural interventions were identified, with data reported in ten papers. Five studies reported statistically significant improvements in pain, measured in a variety of ways, in children randomised to receive interventions based on cognitive behavioural therapy compared to children on wait lists or receiving standard medical care (Duarte 2006; Humphreys 1998; Robins 2005; Sanders 1989; Sanders 1994). The remaining trial (Hicks 2003) included a wider group of children with recurrent pain and too few with only RAP to provide interpretable data.

AUTHORS' CONCLUSIONS

The included trials were small, with methodological weaknesses and a number failed to give appropriate detail regarding numbers of children assessed. In spite of these methodological weaknesses and the clinical heterogeneity, the consistency and magnitude of the effects reported provides some evidence that cognitive behavioural therapy may be a useful intervention for children with recurrent abdominal pain although most children, particularly in primary care, will improve with reassurance and time.

The minicolumnopathy of autism: A link between migraine and gastrointestinal symptoms

Gastrointestinal symptoms are common medical problems among autistic patients. A leaky gut and viruses have been proposed as possible culprits but evidence for these etiological agents remains elusive. In this article, we put forward an alternate etiology: abdominal migraines. Recent postmortem studies in autism indicate the presence of a minicolumnopathy and its relationship to both serotonergic abnormalities and a hyperexcitable cortex. These features of phenomenology are also observed in miganeurs. A putative relationship between autism and migraine is further suggested by similarities in clinical histories and laboratory evidence. Some commonalities include the presence of neuroinflammation, sensory overstimulation (e.g., flickering of fluorescent lights), "food allergies", benefits from similar diets, and the role of nitric oxide. Abdominal migraine therefore stands as a falsifiable hypothesis with added importance accrued to potential therapeutic interventions.

Functional gastrointestinal disorders in migrainous children: efficacy of flunarizine

The aim of this study was to evaluate the prevalence of functional gastrointestinal disorders (FGIDs) in children with migraine headache and the effects of flunarizine on gastrointestinal manifestations. We studied 50 migrainous children (mean age 8.63 years). The clinical pattern and the diagnosis of FGIDs were obtained from structured questionnaires. All subjects underwent measurement of total gastric emptying time (TGEt) performed by real-time ultrasonography of the gastric antrum at baseline (T0). In the second part of the study, we evaluated 10 migrainous children (mean age 9.8 years) with associated FGIDs. In these 10 patients, repeated TGEt evaluation together with a detailed symptom history was obtained after 1 (T1) and 2 months (T2) of treatment with flunarizine. Control groups were composed of 10 migrainous children without FGIDs (mean age 9.2 years) and nine sex- and age-matched healthy children. Gastrointestinal disorders were present in 70% of the patients. Migrainous children with FGIDs had significantly (P < 0.01) more prolonged TGEt than subjects without FGIDs. Prior to therapy, all migrainous children with FGIDs had prolongation of TGEt compared with controls (P < 0.05). Patients on flunarizine had a significant decrease in TGEt at both 1 (P < 0.01) and 2 months (P = 0.002) of therapy. The mean frequency of abdominal pain per month was significantly (P < 0.001) reduced at T1 compared with T0. The mean frequency of vomiting per month was significantly decreased at T1 (P < 0.05) and even more so at T2 (P < 0.01). Finally, the mean frequency of headache per month was significantly reduced only at T2 (P < 0.05), whereas the mean duration of headache was significantly decreased at T1 (P < 0.01) with no difference between T1 and T2. Most children with migraine report FGIDs, associated with a delayed gastric emptying. Flunarizine decreases the frequency and duration of migrainous episodes as well as the gastrointestinal symptoms.

Evaluation of guided imagery as treatment for recurrent abdominal pain in children: a randomized controlled trial

Background

Because of the paucity of effective evidence-based therapies for children with recurrent abdominal pain, we evaluated the therapeutic effect of guided imagery, a well-studied self-regulation technique.

Methods

22 children, aged 5 – 18 years, were randomized to learn either breathing exercises alone or guided imagery with progressive muscle relaxation. Both groups had 4-weekly sessions with a therapist. Children reported the numbers of days with pain, the pain intensity, and missed activities due to abdominal pain using a daily pain diary collected at baseline and during the intervention. Monthly phone calls to the children reported the number of days with pain and the number of days of missed activities experienced during the month of and month following the intervention. Children with ≤ 4 days of pain/month and no missed activities due to pain were defined as being healed. Depression, anxiety, and somatization were measured in both children and parents at baseline.

Results

At baseline the children who received guided imagery had more days of pain during the preceding month (23 vs. 14 days, P = 0.04). There were no differences in the intensity of painful episodes or any baseline psychological factors between the two groups. Children who learned guided imagery with progressive muscle relaxation had significantly greater decrease in the number of days with pain than those learning breathing exercises alone after one (67% vs. 21%, P = 0.05), and two (82% vs. 45%, P < 0.01) months and significantly greater decrease in days with missed activities at one (85% vs. 15%, P = 0.02) and two (95% vs. 77%. P = 0.05) months. During the two months of follow-up, more children who had learned guided imagery met the threshold of ≤ 4 day of pain each month and no missed activities (RR = 7.3, 95%CI [1.1,48.6]) than children who learned only the breathing exercises.

Conclusion

The therapeutic efficacy of guided imagery with progressive muscle relaxation found in this study is consistent with our present understanding of the pathophysiology of recurrent abdominal pain in children. Although unfamiliar to many pediatricians, guided imagery is a simple, noninvasive therapy with potential benefit for treating children with RAP.

Diagnosing migraine in the pediatric population

Migraine in the pediatric population remains substantially underdiagnosed and undertreated. The recently revised International Classification of Headache Disorders is a step in the right direction to improve our diagnostic accuracy. This article reviews the practical diagnostic issues related to migraine in the pediatric population.

Chronic abdominal pain of functional origin in children

Many future investigations into FGIDs are needed. These should focus on refining and validating the Rome diagnostic criteria, investigating possible biologic markers of these disorders, elucidating the role of the visceral afferent dysfunction or reflex motor responses that lead to symptoms, searching for new pathogenic factors (eg, corticotrophin-releasing factor), and evaluating therapies in prospective controlled trials. To tackle this challenging group of disorders successfully, there must be a broad collaboration among basic scientists, clinical investigators, physicians, psychologists, and practitioners of alternative and complementary medicine to develop and evaluate improved therapies. In the meantime, it is our duty as practitioners to keep updated and receptive to the needs of patients and families to reduce patient suffering, improve functioning, and control the costs to society.

Childhood functional gastrointestinal disorders: child/adolescent

The Rome II pediatric criteria for functional gastrointestinal disorders (FGIDs) were defined in 1999 to be used as diagnostic tools and to advance empirical research. In this document, the Rome III Committee aimed to update and revise the pediatric criteria. The decision-making process to define Rome III criteria for children aged 4-18 years consisted of arriving at a consensus based on clinical experience and review of the literature. Whenever possible, changes in the criteria were evidence based. Otherwise, clinical experience was used when deemed necessary. Few publications addressing Rome II criteria were available to guide the committee. The clinical entities addressed include (1) cyclic vomiting syndrome, rumination, and aerophagia; 2) abdominal pain-related FGIDs including functional dyspepsia, irritable bowel syndrome, abdominal migraine, and functional abdominal pain; and (3) functional constipation and non-retentive fecal incontinence. Adolescent rumination and functional constipation are newly defined for this age group, and the previously designated functional fecal retention is now included in functional constipation. Other notable changes from Rome II to Rome III criteria include the decrease from 3 to 2 months in required symptom duration for noncyclic disorders and the modification of the criteria for functional abdominal pain. The Rome III child and adolescent criteria represent an evolution from Rome II and should prove useful for both clinicians and researchers dealing with childhood FGIDs. The future availability of additional evidence-based data will likely continue to modify pediatric criteria for FGIDs.

Functional gastrointestinal disorders in African American children in primary care

OBJECTIVE

To determine the prevalence of functional gastrointestinal disorders (FGIDs) in a primary care setting and to assess the usefulness of pediatric Rome criteria.

METHODS

The Questionnaire on Pediatric Gastrointestinal Symptoms (QPGS) assessing the pediatric Rome criteria was administered to 243 school-age children visiting a general pediatric clinic for annual school physicals. Pearson chi statistics were used to determine the association of various demographic factors with FGIDs.

RESULTS

All children were African American, 47.7% were girls, and the mean +/- standard deviation age of the group was 10.7 +/- 3.9 years. QPGS detected 52 children (21.4%) with FGID. Diagnoses included aerophagia (6), abdominal migraine (1), cyclic vomiting syndrome (2), functional dyspepsia (2), functional abdominal pain syndrome (1), functional constipation (39) and functional fecal retention (1). Thorough clinical evaluation identified 47 (19.3%) children with FGIDs. Five of the children (2.1%) identified as having FGID on QPGS were felt not to have FGID by the examining physician. Children with FGIDs were not different from healthy children in age, insurance, parent's education, employment or number of children in the family. FGIDs were more common in girls (29/47 girls, P = 0.028). Children with FGIDs tended to live in single-parent households and miss school more often than children without FGIDs (P = 0.08).

CONCLUSIONS

Functional gastrointestinal disorders are common among African American children and adolescents in a primary care setting and predominantly affect girls. Symptom-based criteria are useful in the diagnosis of pediatric FGIDs.

Adult abdominal migraine: a new syndrome or sporadic feature of migraine headache? A case report

Abdominal migraine is one of the variants of migraine headache typically occurring in children and coded as 1.3.2 in the revised edition of IHS classification within the group 'Childhood periodic syndromes that are commonly precursors of migraine'. The affected children frequently develop typical migraine later in their life. We report a case of a 23 years old woman affected by attacks of recurrent abdominal pain accompanied by migraine. Abdominal pain attacks started in the adolescence and persisted without headache until the patient was 21. At this time, she experienced migraine pain accompanied by nausea, photophobia and phonophobia and associated to acute abdominal pain. Neuroimaging investigations and laboratory testing excluded any underlying organic disease. Complete remission of abdominal attacks was obtained during 4-month treatment period with pizotifen. Attacks fulfil IHS diagnostic criteria for 'abdominal migraine', although of late onset. This case report suggests that 'abdominal migraine' is a migraineous disorder to be hypothesized in adult patients after having disclosed any organic disease. As reported in the literature, 'adult abdominal migraine' is a sporadic migraine subtype in adult patients and it is not to be considered as a new migraineous syndrome.

Extracephalic tenderness and pressure pain threshold in children with headache

BACKGROUND

Sensitisation of the pain detection system has been suggested to be involved in the pathogenesis of recurrent headache. In adults, increased sensitivity to pain has been found in patients with chronic tension type headache. Children with migraine or with unspecific headache report non-headache pains and interictal pericranial muscular tenderness more often than headache-free children.

OBJECTIVE

To study if children with different types of headache report non-headache pain more often than children with no headache and if extracephalic muscular tenderness is different in children with headache in comparison to headache-free children. To find out if interval to the headache episode has influence on the extracranial muscular tenderness.

DESIGN

A population-based sample of 13-year-old children with migraine (n=48), episodic tension type headache (61) or no headache (59) were interviewed for the occurrence and characteristics of headache and fulfilled a questionnaire on non-headache pain. A structured manual palpation test on muscular tenderness and a pain threshold measurement were done on seven cephalic and three extracephalic points.

RESULTS

Children with migraine reported other pains, especially stomach pain and limb pain more often than children with episodic tension type or no headache. There were no significant differences in the extracephalic muscular tenderness or in the pressure pain thresholds between the three groups.

CONCLUSIONS

Children with migraine experience more non-headache pains than children with episodic tension type headache and with no headache. However, neither children with migraine nor children with episodic tension type headache show increased interictal extracephalic muscular sensitivity for palpation.

How do we diagnose migraine and childhood periodic syndromes?

Migraine remains substantially underdiagnosed and undertreated in the pediatric population. The incidence and prevalence of migraine in the pediatric population is not fully appreciated. The recently revised International Headache Society (IHS) criteria, The International Classification of Headache Disorders, is a step in the right direction to improving our diagnostic accuracy. These criteria are the basis for scientific studies and serve as the foundation for future research and clinical care. In this article, the diagnostic issues related to migraine and childhood periodic syndromes in the IHS 2004 revisions are reviewed.

Validation of the pediatric Rome II criteria for functional gastrointestinal disorders using the questionnaire on pediatric gastrointestinal symptoms

OBJECTIVE

To validate the pediatric Rome II criteria for functional gastrointestinal disorders (FGIDs) using the Questionnaire on Pediatric Gastrointestinal Symptoms (QPGS).

METHODS

Subjects were 315 consecutive new patients, 4 to 18 years of age, seen in a tertiary care clinic and classified by pediatric gastroenterologists as having a functional problem. Patients and parents separately completed the QPGS before medical consultation. Diagnoses were derived using computer algorithms reflecting the Rome II criteria for pediatric FGIDs. Convergent validity was assessed by prevalence of diagnoses and internal validity using factor analysis to confirm symptom clusters of the criteria. Separate analyses were performed for 4 to 9 and 10 to 18 year olds, and for diagnoses based on parent and child reports.

RESULTS

In both age groups, the most prevalent diagnoses were irritable bowel syndrome (IBS) (22.0%, 35.5%), functional constipation (19.0%, 15.2%), and functional dyspepsia (FD) (13.6%, 10.1%). Parent-child concordance on diagnoses was generally poor. Factor analyses supported the internal validity of FD and of IBS symptoms except for relief with defecation. Although functional abdominal pain syndrome and abdominal migraine occurred rarely, symptom clustering within each diagnosis supports their validity. Among patients with abdominal pain, duration was of at least 3 months in most, and pain was of long duration and severe in at least one third.

CONCLUSION

More than half of patients classified as having a functional problem met at least one pediatric Rome II diagnosis for FGIDs. This study offers initial support for the validity of several of the criteria.

Childhood periodic syndromes and migraine

Headache in the pediatric population remains substantially underdiagnosed and undertreated. The recently revised International Headache Society (IHS) criteria, The International Classification of Headache Disorders, is a step in the right direction to improve our diagnostic accuracy. In this article, the diagnostic issues related to childhood periodic syndromes and migraine in the IHS 2004 revisions are reviewed.

Chronic abdominal pain in children

Chronic abdominal pain, defined as long-lasting intermittent or constant abdominal pain, is a common pediatric problem encountered by primary care physicians, medical subspecialists, and surgical specialists. Chronic abdominal pain in children is usually functional, that is, without objective evidence of an underlying organic disorder. The Subcommittee on Chronic Abdominal Pain of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition has prepared this report based on a comprehensive, systematic review and rating of the medical literature. This report accompanies a clinical report based on the literature review and expert opinion. The subcommittee examined the diagnostic and therapeutic value of a medical and psychological history, diagnostic tests, and pharmacologic and behavioral therapy. The presence of alarm symptoms or signs (such as weight loss, gastrointestinal bleeding, persistent fever, chronic severe diarrhea, and significant vomiting) is associated with a higher prevalence of organic disease. There was insufficient evidence to state that the nature of the abdominal pain or the presence of associated symptoms (such as anorexia, nausea, headache, and joint pain) can discriminate between functional and organic disorders. Although children with chronic abdominal pain and their parents are more often anxious or depressed, the presence of anxiety, depression, behavior problems, or recent negative life events does not distinguish between functional and organic abdominal pain. Most children who are brought to the primary care physician's office for chronic abdominal pain are unlikely to require diagnostic testing. Pediatric studies of therapeutic interventions were examined and found to be limited or inconclusive.

The epidemiology of migraine

This article provides a review of the epidemiology and risk factors for migraine in population studies, as well as patterns for healthcare use. The burden and costs of migraine, as well as risk factors for disease progression, are also discussed. Although migraine is a remarkably common cause of temporary disability, many persons with migraine, even those with disabling headache, have never consulted a physician for the problem. Prevalence is highest in women, in persons between the ages of 25 and 55 years, and, at least in the United States, in individuals from lower income households. However, prevalence is high in groups other than these high-risk groups. In a subgroup of patients, migraine may be a progressive disorder.

Chronic Abdominal Pain In Children: a Technical Report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Chronic abdominal pain, defined as long-lasting intermittent or constant abdominal pain, is a common pediatric problem encountered by primary care physicians, medical subspecialists and surgical specialists. Chronic abdominal pain in children is usually functional-that is, without objective evidence of an underlying organic disorder. The Subcommittee on Chronic Abdominal Pain of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition has prepared this report based on a comprehensive, systematic review and rating of the medical literature. This report accompanies a clinical report based on the literature review and expert opinion. The subcommittee examined the diagnostic and therapeutic value of a medical and psychologic history, diagnostic tests, and pharmacological and behavioral therapy. The presence of alarm symptoms or signs (such as weight loss, gastrointestinal bleeding, persistent fever, chronic severe diarrhea and significant vomiting) is associated with a higher prevalence of organic disease. There was insufficient evidence to state that the nature of the abdominal pain or the presence of associated symptoms (such as anorexia, nausea, headache and joint pain) can discriminate between functional and organic disorders. Although children with chronic abdominal pain and their parents are more often anxious or depressed, the presence of anxiety, depression, behavior problems or recent negative life events does not distinguish between functional and organic abdominal pain. Most children who are brought to the primary care physician's office for chronic abdominal pain are unlikely to require diagnostic testing. Pediatric studies of therapeutic interventions were examined and found to be limited or inconclusive.

Efficacy of flunarizine in the prophylaxis of cyclical vomiting syndrome and abdominal migraine

Cyclical vomiting syndrome (CVS), and abdominal migraine (AM) are relatively unusual periodic syndromes, generally believed to be migraine equivalents, and are characterized by recurrent and severe paroxysmal episodes of vomiting and/or abdominal pain lasting hours to days, separated by weeks to months of no symptoms. Flunarizine is a calcium channel-blocking agent that has been used successfully as a prophylactic agent in the prevention of both childhood and adult-onset migraine syndromes. The purpose of this study was to evaluate the efficacy of flunarizine as a prophylactic/preventive agent in the treatment of CVS and AM. Eight children with CVS and 10 children with AM were included in the study. The mean dose of flunarizine was 5 mg/day in children with CVS, and 7.5 mg/day in children with AM. Follow-up ranged from 6 to 24 months (mean 13 months). There was a 57% reduction in frequency and 44% reduction in duration of attacks of CVS, and a 61% reduction in frequency and 51% reduction in duration of attacks of AM. Sixty-four percent of patients with CVS and AM had history of episodic recurrent headaches with 60% reduction in frequency of attacks on treatment. Flunarizine showed to be equally efficacious than previously tried therapies in the prophylaxis of a small cohort of patients with CVS and AM.

Recurrent abdominal pain, anxiety, and depression in primary care

OBJECTIVE

The prevalence of psychiatric disorder in children and adolescents with functional recurrent abdominal pain (RAP) is unknown. Our aim was to determine whether RAP is associated with psychiatric symptoms and disorders, anxious temperament, and functional impairment in pediatric primary care.

METHODS

Children and adolescents who were 8 to 15 years of age, inclusive, and presented with RAP (N = 42) or for routine care in the absence of recurrent pain (N = 38) were identified by a screening procedure in pediatric primary care office waiting rooms and recruited to participate in a case-control study. Outcome measures were psychiatric diagnoses generated by standardized psychiatric interview administered blind to subject status and self, parent, and clinician ratings of child psychiatric symptoms, temperamental traits, and functional status.

RESULTS

RAP patients were significantly more likely to receive a diagnosis of a psychiatric disorder, with a categorical anxiety disorder in 33 (79%) and a depressive disorder in 18 patients (43%), and higher levels of anxiety and depressive symptoms, temperamental harm avoidance, and functional impairment than control subjects. Anxiety disorders (mean age of onset: 6.25 [standard deviation: 2.17] years) were significantly more likely to precede RAP (mean age of onset: 9.17 [standard deviation: 2.75] years) in patients with associated anxiety.

CONCLUSIONS

Youths who present with RAP in primary care deserve careful assessment for anxiety and depressive disorders. Future studies should examine treatments that are proved to be efficacious for pediatric anxiety and/or depressive disorders as potential interventions for RAP. Longitudinal, family, and psychobiological studies are needed to illuminate the nature of observed associations among RAP, anxiety, and depression.

Abdominal migraine and cyclical vomiting

Vomiting and abdominal pain are symptoms that may arise from a number of different causes. Cyclical vomiting and abdominal migraine are terms that have been applied to a presentation characterized by its episodic pattern and intervals of complete health. The 2 share many clinical features, but it is important to distinguish them as they have different responses to therapies such as prophylactic antimigraine medications. Both are noted for the absence of pathognomonic clinical features but also for the large number of other conditions to be considered in their differential diagnoses. Definitive diagnosis is frequently delayed. It is important to carefully evaluate these patients as well-being between vomiting episodes does not guarantee the absence of organic disease. While there is a role for a basic set of diagnostic tests, there is evidence to suggest that a trial of empiric therapy with upper gastrointestinal and small-bowel radiological studies is cost-effective.

Cyclic vomiting syndrome: a brain-gut disorder

Despite the "black box" surrounding CVS, the authors' understanding of this clinical entity has advanced substantially in the last decade as a result of an international interdisciplinary clinical and research effort. Although CVS is now recognized as a unique clinical entity, patients still undergo innumerable hospitalizations and diagnostic tests. Although controlled therapeutic studies are lacking, reasonably effective empiric approaches have been developed by trial and error using anti-migraine, anti-emetic, and anti-epileptic regimens. The ongoing investigations of migraine mechanisms through NMR spectroscopy, mitochondrial DNA mutations and cellular energetics, corticotropin-releasing factor and gastric motility, and brainstem regulation of autonomic function may lead to breakthroughs in the understanding of and new therapies for CVS in the next decade.

Abdominal migraine: evidence for existence and treatment options

There is evidence to suggest that, in children, episodic abdominal pain occurring in the absence of headache may be a migrainous phenomenon. There are four separate strands of evidence for this: the common co-existence of abdominal pain and migraine headaches; the similarity between children with episodic abdominal pain and children with migraine headaches, with respect to social and demographic factors, precipitating and relieving factors, and accompanying gastrointestinal, neurological and vasomotor features; the effectiveness of nonanalgesic migraine therapy (such as pizotifen, propanolol, cyproheptadine and the triptans) in abdominal migraine; and the finding of similar neurophysiological features in both migraine headache and abdominal migraine. Abdominal migraine is rare, but not unknown, in adults. Many families are content with a diagnosis and reassurance that the episodes, though distressing, are not the result of serious pathology. Some patients respond to simple dietary and other prophylactic measures. There is scant evidence on which to base recommendations for the drug management of abdominal migraine. What little literature exists suggests that the antimigraine drugs pizotifen, propanolol and cyproheptadine are effective prophylactics. Nasal sumatriptan (although not licensed for pediatric use) may be effective in relieving abdominal migraine attacks.

Pharmacological interventions for recurrent abdominal pain (RAP) in childhood

BACKGROUND

Between 4% and 25% of school age children complain of recurrent abdominal pain (RAP) of sufficient severity to interfere with daily activities. For the majority of such children no organic cause for their pain can be found on physical examination or investigation. Although most children are likely managed by reassurance and simple measures, a large range of interventions has been recommended.

OBJECTIVES

To determine the effectiveness of medication for recurrent abdominal pain in school-age children.

SEARCH STRATEGY

The Cochrane Library (CENTRAL), MEDLINE, EMBASE, CINAHL, ERIC, PsycLIT, LILACS and JICST were searched using a strategy combining (Recurrent OR synonyms) AND (Abdomen OR synonyms) AND (Pain OR synonyms). Where appropriate search filters were employed. In addition, researchers working in this area were asked to identify relevant studies.

SELECTION CRITERIA

Any study in which the majority of participants were school age children fulfilling standard criteria for RAP, and who were allocated by random or quasi-random methods to any drug treatment compared with a placebo or no treatment.

DATA COLLECTION AND ANALYSIS

References identified by the searches were screened against the inclusion criteria by two independent reviewers.

MAIN RESULTS

Only one trial met the inclusion criteria. This cross-over trial in 14 children who met suggested criteria for "abdominal migraine" compared pizotifen and placebo, each given for one month with no washout period. Participants reported a mean of 8.21 (95% CI 2.93, 13.48) fewer days of pain while taking the active drug. They also reported that the mean difference on an "Index of Severity" was -16.21 (95% CI -26.51, -5.90) and on an "Index of Misery" was -56.07 (95% CI -94.07, -18.07).

REVIEWER'S CONCLUSIONS

There is little evidence to suggest that recommended drugs are effective in the management of RAP. At present there seems little justification for the use of these drugs other than in clinical trials. There is an urgent need for trials of all suggested pharmacologic interventions in children with RAP.

Abdominal migraine in children with neurofibromatosis type 1: a case series and review of gastrointestinal involvement in NF1

BACKGROUND

Symptomatic involvement of the gastrointestinal tract in children with neurofibromatosis type 1 (NF1) is rare. Most reported complications in adults are caused by the presence of neurofibromas in the stomach, small bowel, or mesentery. In contrast, abdominal pain in children with NF1 may be the result of nonanatomic causes, such as migraine. There are no previous reports of an association between abdominal migraine and NF1.

METHODS

Children with abdominal migraine were identified from a group of children with NF1, all of whom had been followed up for a minimum of 3 years. Medical records of cases were reviewed independently by two authors. MEDLINE was searched via PubMed for all reports of children with NF1 and any associated gastrointestinal involvement.

RESULTS

Six children with NF1 and intermittent, episodic, severe abdominal pain are reported. Investigations for obstructive or inflammatory causes of abdominal pain were negative. All patients had previously been diagnosed with migraine headaches by a neurologist. In five of the six patients, propranolol (10-15 mg three times daily) resulted in relief of their abdominal pain within days of starting therapy. Our review identified 24 children in the medical literature with gastrointestinal complications of NF1, mostly secondary to visceral neurofibromas. In almost all of these cases, clinical examination and simple radiologic investigations led to the definitive diagnosis. There were no reports of abdominal migraine complicating NF1.

CONCLUSIONS

Abdominal pain secondary to migraine is an unrecognized cause of abdominal pain in children with NF1 and may be more common than anatomic causes of abdominal pain in children with NF1. In children with NF1 and severe recurrent abdominal pain in whom an evaluation for anatomic lesions is negative, a trial of migraine therapy may be indicated.

Adult outcomes of pediatric recurrent abdominal pain: do they just grow out of it?

OBJECTIVE

To determine whether medically unexplained recurrent abdominal pain (RAP) in childhood predicts abdominal pain, irritable bowel syndrome (IBS), other somatic complaints, and psychiatric symptoms and disorders in young adulthood.

METHODS

A sample of 28 young adults evaluated for RAP between the ages of 6 and 17 years were compared with 28 individually matched former childhood participants in a study of tonsillectomy and adenoidectomy. RAP caseness was established by structured retrospective chart review requiring agreement by 2 independent reviewers. Standardized assessments of abdominal pain, IBS, other somatic symptoms, psychopathology, perceived health, and history of maltreatment were performed an average of 11.1 years after the index visit.

RESULTS

Former RAP patients were significantly more likely than controls to endorse anxiety symptoms and disorders, hypochondriacal beliefs, greater perceived susceptibility to physical impairment, poorer social functioning, current treatment with psychoactive medication, and generalized anxiety in first degree relatives. There were trends suggesting associations between childhood RAP and lifetime psychiatric disorder, depression, migraine, and family history of depression, but group differences on abdominal pain, IBS, other somatic symptoms, and history of maltreatment were not statistically significant.

CONCLUSIONS

There is a strong and relatively specific association between childhood RAP and anxiety in young adulthood. Affected children may be at special risk to perceive physical symptoms as threatening, and should be evaluated for psychiatric disorder on initial presentation.