Abdominal migraine: evidence for existence and treatment options

The kynurenine pathway of tryptophan metabolism in abdominal migraine in children - A therapeutic potential?

BACKGROUND

Abdominal migraine (AM) is a clinical diagnosis specified by Rome IV and ICHD III as a functional gastrointestinal disease (FGID) and a migraine associated syndrome, respectively. Abdominal migraine in childhood and adolescence may continue with migraine headaches in adulthood. This disease is undiagnosed and undertreated, and thus far the FDA has not approved any drug for AM treatment. It was shown that changes in the kynurenine (KYN) pathway of tryptophan (TRP) metabolism played an important role in the pathogenesis and treatment of FIGDs and associated mood disorders. Changes in the KYN pathway were shown in migraine and therefore it may be involved in AM pathogenesis.

FINDINGS

Abdominal migraine reflects an impairment in the communication within the gut-brain axis. Treatment approaches in AM are based on the experience of physicians, presenting personal rather than evidence-based practice, including efficacy of some drugs in adult migraine. Non-pharmacological treatment of AM is aimed at preventing or ameliorating AM triggers and is based on the STRESS mnemonic. Metabolic treatments with riboflavin and coenzyme Q10 were effective in several cases of pediatric migraine, but in general, results on metabolic treatment in migraine in children are scarce and nonconclusive. Modulations within the KYN pathway of TRP metabolism induced by changes in TRP content in the diet, may ameliorate FGIDs and support their pharmacological treatment. Pharmacological manipulations of brain KYNs in animals have brought promising results for clinical applications. Obese children show a higher headache prevalence and may be especially predisposed to AM, and KYN metabolites showed an alternated distribution in obese individuals as compared with their normal-weight counterparts.

CONCLUSIONS

In conclusion, controlled placebo-based clinical trials with dietary manipulation to adjust the amount of the product of the KYN pathway of TRP metabolism are justified in children and adolescents with AM, especially those with coexisting obesity. Further preclinical studies are needed to establish details of these trials.

Migraine and Its Equivalents: What Do They Share? A Narrative Review on Common Pathophysiological Patterns

Migraine is the first in order of frequency of the neurological disorders, affecting both adult and paediatric populations. It is also the first cause of primary headaches in children. Migraine equivalents are periodic disorders that can be associated with migraine or considered as prognostic features of a future migraine manifestation. Despite the mechanisms underlying migraine and its equivalents are not entirely clear, several elements support the hypothesis of common pathophysiological patterns shared by these conditions. The aim of this review is thus to analyze the literature in order to highlight which currently known mechanisms may be common between migraine and its equivalents.

Fifty-eight-year-old female with abdominal migraine: A rare cause of episodic gastrointestinal disturbance in adults

Abdominal migraine (AM) is a predominantly pediatric condition characterized by erratic episodes of abdominal pain, nausea, and vomiting with spontaneous periodic relief. It should be considered as a differential diagnosis in symptomatic adults.

Management of Childhood Headache in the Emergency Department. Review of the Literature

Headache is the third cause of visits to pediatric emergency departments (ED). According to a systematic review, headaches in children evaluated in the ED are primarily due to benign conditions that tend to be self-limiting or resolve with appropriate pharmacological treatment. The more frequent causes of non-traumatic headache in the ED include primitive headaches (21.8–66.3%) and benign secondary headaches (35.4–63.2%), whereas potentially life-threatening (LT) secondary headaches are less frequent (2–15.3%). Worrying conditions include brain tumors, central nervous system infections, dysfunction of ventriculo-peritoneal shunts, hydrocephalus, idiopathic intracranial hypertension, and intracranial hemorrhage. In the emergency setting, the main goal is to intercept potentially LT conditions that require immediate medical attention. The initial assessment begins with an in-depth, appropriate history followed by a complete, oriented physical and neurological examination. The literature describes the following red flags requiring further investigation (for example neuroimaging) for recognition of LT conditions: abnormal neurological examination; atypical presentation of headaches: subjective vertigo, intractable vomiting or headaches that wake the child from sleep; recent and progressive severe headache (<6 months); age of the child <6 years; no family history for migraine or primary headache; occipital headache; change of headache; new headache in an immunocompromised child; first or worst headache; symptoms and signs of systemic disease; headaches associated with changes in mental status or focal neurological disorders. In evaluating a child or adolescent who is being treated for headache, physicians should consider using appropriate diagnostic tests. Diagnostic tests are varied, and include routine laboratory analysis, cerebral spinal fluid examination, electroencephalography, and computerized tomography or magnetic resonance neuroimaging. The management of headache in the ED depends on the patient's general conditions and the presumable cause of the headache. There are few randomized, controlled trials on pharmacological treatment of headache in the pediatric population. Only ibuprofen and sumatriptan are significantly more effective than placebo in determining headache relief.

Pediatric abdominal migraine: current perspectives on a lesser known entity

Background

Abdominal migraine (AM) is a common cause of chronic and recurrent abdominal pain in children. It is characterized by paroxysms of moderate to severe abdominal pain that is midline, periumbilical, or diffuse in location and accompanied by other symptoms including headache, anorexia, nausea, vomiting, or pallor. Despite the presence of comprehensive diagnostic criteria under Rome IV classification of functional gastrointestinal disorders (FGIDs) and International Classification of Headache Disorders, it continues to be an underdiagnosed entity.

Overview

The average age of diagnosis is 3–10 years with peak incidence at 7 years. Most of the patients have a personal or family history of migraine. Pathophysiology of the condition is believed to be similar to that of other FGIDs and cephalic migraine. It is also well recognized as a type of pediatric migraine variant. A careful history, thorough physical examination, and use of well-defined, symptom-based guidelines are needed to make a diagnosis. Selective or no testing is required to support a positive diagnosis. It resolves completely in most of the patients. However, these patients have a strong propensity to develop migraine later in life. Explanation and reassurance should be the first step once the diagnosis is made. Nonpharmacologic treatment options including avoidance of triggers, behavior therapy, and dietary modifications should be the initial line of management. Drug therapy should be considered only if symptoms are refractory to these primary interventions.

Conclusion

More research focused on pathophysiology and management of AM needs to be carried out to improve outcomes in affected children.

Effect of exclusion of frequently consumed dietary triggers in a cohort of children with chronic primary headache

BACKGROUND

Although dietary factors are known to trigger headaches, the relationship between food and headache in children remains unclear. This prospective, observational case series aimed to evaluate the effect of exclusion of frequently-consumed foods in a cohort of children with headache.

METHODS

One hundred and fifteen children aged 3-15 (mean 10.5) years with primary headache were followed in a paediatric outpatient clinic. Patients who frequently consumed foods or food additives known to trigger headaches were advised to exclude them for six weeks and to return for follow-up with headache and food diary.

RESULTS

One hundred patients attended follow-up. Of these 13 (13%) did not respond to dietary exclusion; 87 (87%) achieved complete resolution of headaches by exclusion of 1-3 of the identified food(s). Caffeine was the most common implicated trigger (28), followed by monosodium glutamate (25), cocoa (22), aspartame (13), cheese (13), citrus (10) and nitrites (six). One patient was sensitive to tomatoes.

CONCLUSIONS

This study demonstrates the potential scale and significance of seven frequently consumed foods or food additives as triggers for primary headache in children. Also this is the first study to show that headaches can be triggered by the cumulative effect of a food that is frequently consumed, rather than by single time ingestion.

Migraine Variants or Episodic Syndromes That May Be Associated With Migraine and Other Unusual Pediatric Headache Syndromes

PURPOSE

To provide an overview of the clinical course for children and adolescents with migraine variants (M.V.), childhood periodic syndromes or the episodic syndromes that may be associated with migraine using the International Classification of Headache Disorders, 3rd Edition Beta version [ICHD-3] International Headache Society criteria for the diagnosis of each disorder.

METHOD

Migraine is a complex set of neurological symptoms. This review encompasses the subtypes of M.V. or episodic syndromes that may be associated with migraine within the children and adolescent population.

CONCLUSION

The episodic syndromes that may be associated with migraine or migraine variant is multilayered neurological disorder in young children and adolescents. Within the these generally pediatric syndromes there are associated disorders described in this review, to provide a clinical overview and including the less common forms of migraine, such as acute confusional migraine, trauma-triggered migraine, and transient global amnesia.

Abdominal migraine

Background

Abdominal migraine (AM) is a syndrome usually recognised in childhood. The syndrome is characterised by episodic attacks of severe abdominal pain and vasomotor symptoms, nausea and vomiting. It is a poorly understood disorder largely due to a limited recognition of this condition by the medical community. However, the publication of AM diagnostic guidelines by the International Headache Society a decade ago and the recognition of AM in the Rome Classification of functional gastrointestinal disorders have helped to legitimise this disorder and facilitate research.

Overview

AM is relatively common, affecting up to 4% of the paediatric population. Whilst AM is not believed to continue into adulthood for the majority of children, it has the propensity to develop into probable migraine and recurrent abdominal pain in adulthood. The pathophysiology of this condition remains unclear and as a result treatment for this condition is suboptimal with avoidance of triggers and prophylactic treatment currently recommended when an episode begins.

Conclusion

The recognition of AM by the IHS and the Rome Foundation should help facilitate future research into the pathophysiology of this debilitating condition and as a result better treatments for AM should emerge. Randomised controlled trials should be a priority.

Pediatric migraine variants: a review of epidemiology, diagnosis, treatment, and outcome

Pediatric migraine variants, previously known as childhood periodic syndromes, migraine equivalents, or migraine precursors, are a group of periodic or paroxysmal disorders occurring in patients who also have migraine with or without aura, or who have an increased likelihood of developing migraine. They have common key clinical features including periodic or paroxysmal character, normal neurological examination between attacks, family history of migraine, and clinical evolution to classic types of migraine. This article aims to review the pathophysiology, evaluation, and management of the pediatric migraine variants including abdominal migraine, benign paroxysmal vertigo, cyclic vomiting syndrome, and benign paroxysmal torticollis as well as the episodic syndromes that may lead to migraine, infantile colic, alternating hemiplegia of childhood, and vestibular migraine.

Abdominal Migraine

Abdominal migraine is one of the episodic syndromes that may be associated with migraine, which often has its initial presentation in childhood. Recognition of these 2 conditions in the pediatric population is paramount to establish an appropriate diagnosis, treatment, and prevention. The aim of this article is to review the most recent International Classification of Headache Disorders-3 beta for abdominal migraine, and discuss the differential diagnosis and current suggested management.

The Episodic Syndromes That Maybe Associated with Migraines

The "childhood periodic syndromes" have been renamed "the episodic syndromes that maybe associated with migraines". These syndromes were initially considered precursors of migraines that only occurred in childhood; however recent literature suggests that the episodic syndromes can occur in adults with known migraine and does not necessarily present as a precursor. This review article discusses the recent literature regarding the episodic syndromes and potential treatments. These disorders are seen by multiple subspecialists, therefore it is important to recognize and use the same definitions, criteria and nomenclature. A collaborative and multidisciplinary approach is critical to characterize, manage and potentially improve outcomes.

Mechanisms mediating nitroglycerin-induced delayed-onset hyperalgesia in the rat

Nitroglycerin (glycerol trinitrate, GTN) induces headache in migraineurs, an effect that has been used both diagnostically and in the study of the pathophysiology of this neurovascular pain syndrome. An important feature of this headache is a delay from the administration of GTN to headache onset that, because of GTN's very rapid metabolism, cannot be due to its pharmacokinetic profile. It has recently been suggested that activation of perivascular mast cells, which has been implicated in the pathophysiology of migraine, may contribute to this delay. We reported that hyperalgesia induced by intradermal GTN has a delay to onset of ∼ 30 min in male and ∼ 45 min in female rats. This hyperalgesia was greater in females, was prevented by pretreatment with the anti-migraine drug, sumatriptan, as well as by chronic pretreatment with the mast cell degranulator, compound 48/80. The acute administration of GTN and compound 48/80 both induced hyperalgesia that was prevented by pretreatment with octoxynol-9, which attenuates endothelial function, suggesting that GTN and mast cell-mediated hyperalgesia are endothelial cell-dependent. Furthermore, A-317491, a P2X3 antagonist, which inhibits endothelial cell-dependent hyperalgesia, also prevents GTN and mast cell-mediated hyperalgesia. We conclude that delayed-onset mechanical hyperalgesia induced by GTN is mediated by activation of mast cells, which in turn release mediators that stimulate endothelial cells to release ATP, to act on P2X3, a ligand-gated ion channel, in perivascular nociceptors. A role of the mast and endothelial cell in GTN-induced hyperalgesia suggests potential novel risk factors and targets for the treatment of migraine.

Abdominal Migraine in a Middle-aged Woman

A 52-year-old woman presented with recurrent, severe abdominal pain. Laboratory tests and imaging were insignificant, and treatment for functional dyspepsia was ineffective. The poorly localized, dull, and severe abdominal pain, associated with anorexia, nausea, and vomiting, was consistent with abdominal migraine. The symptoms were relieved by loxoprofen and lomerizine, which are used in the treatment of migraine. We herein report a case of abdominal migraine in a middle-aged woman. Abdominal migraine should be considered as a cause of abdominal pain as it might easily be relieved by appropriate treatment.

Migraine management in children

Migraine management in children relies on understanding the difference between adult and childhood migraine, being able to identify childhood migraine variants and knowledge of both the pediatric and adult literature regarding treatment.

Is Helicobacter pylori infection a risk factor for childhood periodic syndromes?

Background and objectives

Helicobacter pylori (H. pylori) infection has been assumed to have roles in various extra-digestive diseases. The current study was designed to evaluate the incidence of H. pylori infection in patients with cyclic vomiting syndrome and its possible role in the etiology of this disease.

Design and setting

In this case-control study, 120 cases with diagnoses of cyclic vomiting or abdominal migraine who were registered at the Gastroenterology Clinic at Shiraz University of Medical Sciences from 2010 to 2013 were enrolled.

Materials and methods

Primarily information regarding the patients' diseases were collected with a data gathering sheet, and fresh morning stool samples were collected from the patients and examined for H. pylori stool antigen with the H. pylori Ag EIA test kit. The results were compared with those of healthy children from the control group.

Results

A total of 120 patients with cyclic vomiting (47.5%) and abdominal migraine (52.5%) with a mean age of 7.1 ± 3.4 (range 2-16 years) and a male-to-female ratio of 1.6 were included. The HPs Ag tests were positive in only 7 (5.8%) patients in our case group, and the HPs Ag tests were positive in 13 (13%) of the children in the control group; this difference was statistically insignificant.

Conclusion

Our study did not support H. pylori infection as an etiological factor in CV or AM.

Pediatric migraine and episodic syndromes that may be associated with migraine

Importance

Migraine is a common disorder and a frequent cause of medical consultation in children. Many childhood episodic syndromes have been described as common precursors of migraine.

Objective

To review current knowledge on migraine and childhood episodic syndromes, and to discuss future directions for research and clinical practice.

Findings

For most children it is difficult to describe a headache and fully verbalize symptoms such as photophobia and phonophobia that must be inferred from behaviour. Classical migraine features are rare before the age of 6 years, but some migraine-related syndromes have been described. Benign paroxysmal torticollis of infancy, benign paroxysmal vertigo of childhood, cyclic vomiting syndrome and abdominal migraine are currently classified as childhood episodic syndromes, and therefore common precursors of migraine. A strong association between infantile colic and migraine has recently been reported. There are similarities between children with episodic syndromes and children with migraine, regarding social and demographic factors, precipitating and relieving factors, and accompanying gastrointestinal, neurologic, and vasomotor features. The real pathophysiological mechanisms of migraine are not fully understood. Current data obtained through molecular and functional studies provide a complex model in which vascular and neurologic events cooperate in the pathogenesis of migraine attacks. Genetic factors causing disturbances in neuronal ion channels, make a migraineur more sensitive to multiple trigger factors that activate the nociception cascade. The expanding knowledge on migraine genetics and pathophysiology may be applicable to childhood episodic syndromes. Migraine preventive strategies are particularly important in children, and could be beneficial in childhood episodic syndromes. Nonspecific analgesics like ibuprofen and acetaminophen are widely used in pediatrics to control pain and have been found to be effective also in the treatment of acute migraine attacks. Triptans are the specific fist-line drugs for acute migraine treatment.

Conclusions and relevance

Migraine phenotype differs somewhat in the developing brain, and childhood episodic syndromes may arise before typical migraine headache. Diagnosing pediatric migraine may be difficult because of children’s language and cognitive abilities. The risk of underestimating migraine in pediatric age is high. An adequate diagnosis is important to maintain a good quality of life and to avoid inappropriate therapy.

Migraine equivalents in childhood

Migraine equivalents are a group of periodic and paroxysmal neurologic diseases. Because headache is not a prominent symptom, the diagnosis might be challenging. The objective of the study was to evaluate the frequency and outcome of migraine equivalents. This was a retrospective study. We included benign paroxysmal torticollis of infancy, benign paroxysmal vertigo of infancy, abdominal migraine, cyclic vomiting, aura without migraine, and confusional migraine. We evaluated the frequency of events, treatment, and outcome. Out of 674 children with headache, 38 (5.6%) presented with migraine equivalents. Twenty-one were boys and the mean age was 6.1 years. Fifteen had abdominal migraine, 12 benign paroxysmal vertigo, 5 confusional migraine, 3 aura without migraine, 2 paroxysmal torticollis, and 1 cyclic vomiting. Prophylactic treatment was introduced in 23 patients; 4 lost follow-up and 19 had significant improvement. We conclude that the correct diagnosis of migraine equivalents enables an effective treatment with an excellent outcome.

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.

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.

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.

Association of 5-HTT gene polymorphisms with migraine: a systematic review and meta-analysis

BACKGROUND/AIMS

Serotonin is known to play an important role in the pathogenesis of migraine, but individual genetic association studies that examine the relationship between polymorphisms of serotonin transporter (5-HTT) gene and migraine have yielded inconsistent results. This study aimed to evaluate the association between 5-HTT gene variants (including 5-HTTLPR, VNTR and SNP) and migraine using systematic review with meta-analysis.

METHODS

Relevant studies were identified by searching English and Chinese databases extensively. Allele and genotype frequencies for each included study were extracted. The odds ratio (OR) was calculated using a random-effects or fixed-effects model. Q statistic was used to evaluate homogeneity, and Egger's test and Funnel plot were used to assess publication bias. For family-based association studies, a descriptive analysis was carried out.

RESULTS

A total of 15 studies were identified for meta-analysis. It was found that the 5-HTT VNTR Stin2.12 allele or 12/12 genotype had an increased risk for migraine in the general population (Stin2.12 allele: OR, 95% CI: 1.34, 1.09-1.64, p=0.006; 12/12 genotype: OR, 95% CI: 1.55, 1.17-2.05, p=0.002), but there was no significant association between migraine and 5-HTTLPR or SNP rs2020942.

CONCLUSIONS

Existing evidence indicates that the 5-HTT VNTR polymorphism (mainly the STin2.12 genotype) is associated with an increased risk of migraine in the general population. Future studies with larger sample sizes will be necessary to confirm the present results.

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.

Contribution of Serotonin Transporter Gene Polymorphisms to Pediatric Migraine

BACKGROUND

The serotonin transporter gene is a promising candidate locus for the genetic susceptibility of migraine.

OBJECTIVE

Two functional polymorphisms of the serotonin transporter gene (5-HTTLPR and STin2) were analyzed to assess whether these variants are associated with pediatric migraine.

METHODS

Eighty-seven Hungarian pediatric migraine patients and 464 controls were genotyped using polymerase chain reaction. Patients suffering from migraine with (n = 38) or without aura (n = 49) were interviewed regarding the clinical symptoms before or during the attacks.

RESULTS

There was no difference between genotype or allele distribution of 5-HTTLPR and STin2 polymorphisms in the entire group of migraineurs and controls. Analysis of subgroups showed an association between STin2 and migraine with aura, as the 12,12 homozygote genotype was overrepresented in this group of patients. Furthermore, similar allele and genotype patterns were found in cases with severe vomiting and abdominal pain.

CONCLUSIONS

These results confirm and extend the association between the STin2 polymorphism of 5-HTT gene and migraine with aura using pediatric probands. Our data also suggest a novel endophenotype for pediatric migraine characterized by excessive vomiting and abdominal pain during the attack.

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.

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.

The migraine variants

The migraine variants are unique to pediatrics and are a fascinating and challenging group of disorders characterized by the onset of focal neurological signs and symptoms such as hemiparesis, altered consciousness nystagmus, or ophthalmoparesis followed by headache. Because all of the diagnoses discussed represent diagnoses of exclusion, only after a careful medical history, a physical examination, and appropriate neurodiagnostic studies can they be entertained comfortably. Often, these ominous neurological signs initially lead the clinician in the direction of epileptic, cerebrovascular, traumatic, or metabolic disorders, and only after thorough neurodiagnostic testing does the diagnosis become apparent. Some of these entities occur in infants and young children in which the medical history is limited.

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.

Citalopram treatment of pediatric recurrent abdominal pain and comorbid internalizing disorders: an exploratory study

OBJECTIVE

To assess the potential efficacy, tolerability, and safety of citalopram in the treatment of functional pediatric recurrent abdominal pain and comorbid internalizing disorders.

METHOD

Twenty-five clinically referred children and adolescents with recurrent abdominal pain aged 7 to 18 years, inclusive, participated in a 12-week, flexible-dose, open-label trial of citalopram. Primary outcome measure was the Clinical Global Impression Scale-Improvement, with responders defined by ratings of 1 (very much improved) or 2 (much improved). Secondary measures included self- and parent reports of abdominal pain, anxiety, depression, other somatic symptoms, and functional impairment. Side effects were assessed using a standardized checklist. Data were analyzed using an intent-to-treat format and the last observation carried forward procedure.

RESULTS

Twenty-one subjects (84%) were classified as responders (Clinical Global Impression Scale-Improvement score < or =2). Citalopram was generally well tolerated. Four subjects withdrew prematurely, one due to reported visual side effects. Ratings of abdominal pain, anxiety, depression, other somatic symptoms, and functional impairment all improved significantly over the course of the study compared with baseline.

CONCLUSIONS

Citalopram is a promising treatment for functional pediatric recurrent abdominal pain and deserves additional study with a randomized, placebo-controlled clinical trial.

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.