Researchers at the Children's Hospital of the King's Daughters, Norfolk, VA conducted a retrospective chart review on patients referred with the clinical complaint of recurrent abdominal pain, and ICHD-2 criteria were applied to identify those fulfilling criteria for abdominal migraine (AM). Of 458 patients with chronic, idiopathic, recurrent abdominal pain, only 20 (4.4%) met ICHD-2 criteria for AM and another 50 (11%) had probable AM, lacking at least one criterion for the diagnosis. No child seen in this gastroenterology practice between 1/1/2006 and 12/31/2007 had been diagnosed with AM during the 2-year observation period. AM is under-diagnosed in the US. Increased awareness of cardinal features of AM may result in improved diagnosis and early use of specific therapy. ICHD-2 2004 criteria for AM are listed as follows: A. At least 5 attacks with criteria B-D; B. Abdominal pain lasting 1-72 hrs; C Abdominal pain in midline, periumbilical, dull, and moderate or severe; D. At least 2 of the following during pain: anorexia, nausea, vomiting, pallor; E. Pain is not attributed to another disorder, and gastrointestinal or renal disease has been ruled out. [1]

COMMENT. Reasons for exclusion from the diagnosis of abdominal migraine included irritable bowel syndrome (41%), renal disease (4%), pre-existing neurologic disorder (7%), inflammatory bowel disease (16%), eosinophilc esophagitis (4%), and "other" (28%), including food allergies, celiac disease, cystic fibrosis, autism spectrum disorder, and anatomic abnormalities. The differential diagnosis of chronic recurrent abdominal pain in children is broad and may require the expertise of pediatrician, gastroenterologist, psychiatrist, and neurologist. Diagnosis is based on exclusion criteria and positive criteria. Positive ICHD-2 criteria for AM are listed above. Among the neurologic disorders sometimes causative, abdominal epilepsy may be differentiated from migraine by the occurrence of other features of partial seizures, the family history, and an EEG showing interictal epileptiform discharges. Migraine and epilepsy are uncommon causes of recurrent abdominal pain, and investigation of other causes is paramount. My last consultation on a case of recurrent abdominal pain referred for EEG and exclusion of abdominal epilepsy eventually proved to have pancreatitis necessitating surgery.

Childhood abuse and migraine. Neurologists at the Universities of Toledo, OH and Johns Hopkins, Baltimore, MD, review the neurobiological effects of abuse on brain function and structure in relation to migraine [2]. A possible role of early life stress on the pathogenesis of migraine may impact girls more than boys and may become hard-coded into the genome, leading to migraine at a later age. The emerging field of epigenetics may suggest new treatment strategies such as serotonin-specific reuptake inhibitors that reverse effects of maltreatment and decrease the corticotropin releasing hormone response to stress.