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Revista chilena de pediatría

versión impresa ISSN 0370-4106

Rev. chil. pediatr. vol.91 no.1 Santiago feb. 2020  Epub 02-Feb-2020

http://dx.doi.org/10.32641/rchped.v91i1.1250 

ORIGINAL ARTICLE

Abdominal migraines: Variations in diagnosis and care between pediatric gastroenterologists and neurologists

Kathryn Hawa1 

Shivani Gupta1 

Miguel Saps2 

1Nationwide Children's Hospital, Columbus, Ohio, United States.

2University of Miami, Miller School of Medicine, Miami, Florida, United States.

Abstract:

Introduction:

Abdominal migraine (AM) is uncommon and understudied. Our objective was to investigate the diagnosis and treatment of children and adolescents with AM and compare with that of pediatric gastroenterologists and neurologists.

Patients and Method:

All AM cases (1-18 years) from a USA hospital with diagnosis of abdominal migraine or its variants (ICD-9 346.2 or IC-10 G43.D, G43.D0, G43.D1) between 2011 and 2017 were reviewed. Information on diagnosis, interval from onset of symptoms, diagnostic criteria, diagnostic tests, treatment, and outcome were analyzed.

Results:

69 medical records were identified. The mean age at diagnosis was 9.7 years, and 48% of patients were female. 50/69 (72.4%) patients were exclusively treated by a pediatric gastroenterologist and 10/69 (14.5%) exclusively by a pediatric neurologist. 6/69 (8.7%) were initially evaluated by gas troenterology and referred to neurology, and 2/69 (2.9%) were initially evaluated by neurology and then referred to gastroenterology. 3/10 (30%) of the AM diagnosed by neurologists did no report ab dominal pain (AP), however, all diagnoses made by gastroenterologists did (p = 0.0035). 5/50 (10%) of the gastroenterology medical records and no neurology medical records mentioned Rome criteria.

Conclusions:

Most of the children were diagnosed by pediatric gastroenterologists. Gastroenterolo gists rarely use the Rome criteria. Patients evaluated by neurologists are frequently diagnosed with AM even without AP (a criterion that is required for its diagnosis). Education is recommended for the correct and timely diagnosis of AM.

Keywords: Abdominal migraine; migraine; functional gastrointestinal disorders; abdominal pain

Introduction

Abdominal migraine is a rare but highly tasking functional abdominal pain disorder that is exclusively diagnosed in children1,2,3. Abdominal migraine is defi ned by the Rome IV criteria as stereotypical episodes of severe and incapacitating abdominal pain separated by weeks to months of little to no symptoms3. Accor ding to the Rome IV criteria, abdominal pain episodes should be associated with additional co-morbid symp toms such as photophobia, pallor, anorexia, nausea, vomiting or headaches (Table 1)3. Abdominal migraine can also be defined by the International Classification of Headache Disorders (ICHD-3) which requires the presence of abdominal pain associated with vasomo tor symptoms (Table 2)4. The latter criteria is more commonly used by neurologists4. This is relevant as patients with a presumptive diagnosis of abdominal migraine are not always diagnosed and cared for by pediatric gastroenterologists. There is a dearth of data on the standard of care of abdominal migraine, no information on variations of care between pediatric gas troenterologists and neurologists and only one small pharmacologic clinical trial (14 patients) has ever been published. The trial assessed the efficacy of a drug that is not available in the United States (pizotifen)5.

Table 1 Rome IV diagnostic criteria for abdominal migraines.3  

Table 2 ICHD-3 diagnostic criteria for abdominal migraines.4  

In view of the paucity of data of this uncommon disorder, it is of utmost importance to better unders tand the diagnostic criteria and management plans cu rrently used to care for this group of children. Therefo re, our objectives were to investigate current practices in the care of children and adolescents with abdominal migraine in a major Midwest (USA) tertiary care hos pital. Children with abdominal migraine will be diag nosed and cared for either by pediatric neurologists or pediatric gastroenterologists with each specialist following their own societal diagnostic criteria. As the re is no standard of care for abdominal migraines, our objective was to assess for and establish any differences between diagnosis and management between pediatric neurologists and pediatric gastroenterologists.

Patients and Method

Data of all pediatric patients 1-18 years old from Nationwide Children’s Hospital of Columbus, OH, diagnosed with abdominal migraine or its variants (ICD-9 346.2 or IC-10 G43.D, G43.D0, G43.D1) bet ween 2011-2017 were extracted from the database and their charts were reviewed. Information on diagnosis (such as age at diagnosis), interval from onset of symp toms, whether they met diagnostic criteria, diagnostic testing, treatment and outcome were extracted and analyzed between the two specialties. This data was then analyzed statistically using the 2-sample t-test. There were no exclusion criteria as we wanted our sample size to be as large as possible. If they had an aforementioned code after an office visit, they were in cluded. A protocol for this study was written and sub mitted to the IRB (17-00369) and then was approved.

Results

Sixty-nine charts with the diagnosis of abdominal migraine were identified and the physician’s diagnosis was confirmed by chart review. Mean age at the time of diagnosis was 9.7 years, 48% females. Mean initial fo llow up visit was 3.2 months, range 11.5 months. 42/69 (61%) of patients had symptoms for 1 year or lon ger before diagnosis established. Total of 45 patients were found to have follow up within 12 months. 50/69 (72.4%) were cared by pediatric gastroenterologist alone and 10/69 cases (14.5%) were exclusively cared by pediatric neurology. 6/69 (8.7%) were initially seen by pediatric gastroenterologist but later referred to neu rology for diagnosis. 2/69 (2.9%) were initially seen by neurology but then referred to pediatric gastroentero logist for diagnosis. 1/69 (1.5%) was diagnosed and ca red for by the pediatrician. Children who were diagno sed by pediatric neurologist were younger than those diagnosed by pediatric gastroenterologist (p = 0.0038, CI -3.14 to -0.63).

Diagnosis

Although abdominal pain is the driving symptom of abdominal migraine and is required by the ICDH- 3 for its diagnosis, 3/10 (30%) of children diagnosed by neurology did not have abdominal pain while all children diagnosed by pediatric gastroenterologist did (p = 0.0035). 16/50 (32%) of children diagnosed with abdominal migraine by pediatric gastroenterologist and 3/10 (30%) of children diagnosed by pediatric neurologist met Rome III/IV criteria (current criteria at time of diagnosis) (p = 1.0). We cannot conclusively state that some patients did not meet criteria, but pro viders did not write it in the chart or thoroughly descri be their symptoms. 34/50 (68%) of children diagnosed with abdominal migraine by pediatric gastroenterolo gist either did not meet Rome criteria (25/50 (50%)) or had incomplete information on all criteria listed in the Rome III/IV criteria (9/50 (18%)). Thus, no con clusion on whether those children met criteria could be determined. 1/1 (100%) diagnosed by a pediatri cian did not meet Rome criteria. Gastroenterologists referred to the Rome criteria in 5/50 (10%) of charts, whereas there was no mention to the Rome criteria or the International Classification of Headache Disorders in any neurology charts. Of the patients diagnosed by a pediatric neurologist, 6/16 (37.5%) met the ICHD-3 criteria. 10/16 (62.5%) of children diagnosed with ab dominal migraine by a pediatric neurologist either did not meet ICHD-3 criteria (8/10 (80%)) or had incom plete information on all criteria listed in the ICHD-3 criteria (2/10 (20%)).

Laboratory workup

Gastroenterologists frequently conducted labo ratory workup at the time of diagnosis (85%), while none of the patients diagnosed by neurology or general pediatrician underwent diagnostic workup. Following the diagnosis, a subset of patients in both groups had additional workup that included celiac testing, inflam matory markers, complete blood count/chemistries in 35/53 (66%) of patients managed by gastroenterolo gists and 5/16 (31%) of patients managed by pediatric neurologists (p = 0). 6/69 patients received head ima ging (4 patients with MRI head, 2 patients received CT head, all negative for acute findings). In no cases did the laboratory workup result in diagnosis changes.

Treatment

Every patient diagnosed with abdominal migraine received treatment. Excluding medications given in the emergency room, neurologists prescribed either cyproheptadine (56%) or sumatriptan (44%) for the treatment of their patients, while gastroenterologists prescribed a wider range of drugs. These included cy proheptadine (50%), sumatriptan (31%), prometha zine (31%), amitriptyline (22%), hyoscyamine (18%), ondansetron (17%) and dicyclomine (6%). Treatment prescribed by neurology did not differ between those who did or did not have abdominal pain.

Follow-up

6/16 (37.5%) of neurology patients and 16/52 (30.8%) of patients cared by gastroenterology have not had follow up appointments. Out of those who had follow-up by neurologist, 7/16 (44%) of patients treated by neurology evaluated for improvements in headaches and 3/16 (19%) found to have improved abdominal pain (63% total with improved symptoms). 33/36 (92%) of children treated by gastroenterologists reported improved abdominal pain. One patient seen by neurology had spontaneous resolution of all pre vious symptoms including abdominal pain and hea dache and 4 (8%) patients cared by gastroenterology resolved their symptoms with medications.

Discussion

We found that most children with abdominal mi graine are cared for by pediatric gastroenterologists. Contrary to our hypothesis, pediatric neurologists and gastroenterologists do not follow their own societal diagnostic guidelines. Both established criteria, the Rome and International Classification of Headache Disorders, require abdominal pain for its diagnosis. The diagnosis of abdominal migraine is also made in the absence of abdominal pain by non-gastroentero logists. This is of interest as the presence of severe and debilitating abdominal pain is the driving symptom in diagnosis of abdominal migraine. Our study also in dicated that neurologists focused more on headache in their follow up evaluation as the primary symptom with either vomiting and/or abdominal pain as an ad junct symptom.

Not using the diagnostic criteria previously esta blished is problematic for clinical care and research. In terms of patient’s care, it precludes accurate com munication among practitioners at the time of refe rrals as well as transition of care into adulthood. In terms of research, the lack of a “common language” impairs data collection and analysis as patients with a different diagnosis would be aggregated as having ab dominal migraine adding a component of randomness to the investigation. In an uncommon disorder where collaboration to achieve adequate sample size is para mount, the absence of common diagnostic criteria can potentially undermine the success of needed research projects.

The study also found that patients are studied and treated similarly regardless of their diagnostic criteria. The variation in patient management between pedia tric gastroenterologists and neurologists, in the absen ce of evidence-based data, is likely the result of anec dotal experience or unproven style of care. Although one could argue that the high rate of improvement of symptoms regardless of the variations of medical care indicates against the need of standardized evidence-based treatments, very few patients experienced reso lution of their symptoms. The important impact of this recurrent disorder in the child’s health and the latency in diagnosis found in our study should encourage the medical community to achieve a deep knowledge of this disabling disorder. The results of this retrospective cross-sectional study should be taken with caution due to the study design and single center collection of data that cannot assure external validity. There was also a limitation in that we relied very heavily on the infor mation that was documented by physicians. If details or symptoms weren’t documented, we didn’t have another way of knowing if a patient had that symptom. Therefore, the question of whether a patient met crite ria for abdominal migraines could be affected.

In conclusion, we found infrequent use of esta blished diagnostic criteria and high variations in diagnostic workup and treatment in children with abdominal migraine. Large, collaborative multi center clinical trials using common diagnostic cri teria should be conducted to establish the optimal treatment to improve the outcome of children with abdominal migraine.

Ethical Responsibilities

Human Beings and animals protection: Disclosure the authors state that the procedures were followed ac cording to the Declaration of Helsinki and the World Medical Association regarding human experimenta tion developed for the medical community.

Data confidentiality: The authors state that they have followed the protocols of their Center and Local regu lations on the publication of patient data.

Rights to privacy and informed consent: The authors have obtained the informed consent of the patients and/or subjects referred to in the article. This docu ment is in the possession of the correspondence author.

Conflicts of Interest: Authors declare no conflict of interest regarding the present study.

Financial Disclosure: Authors state that no economic support has been asso ciated with the present study.

Referencias:

1. Saps M, Nichols-Vinueza D, Rosen JM, Velasco CA. Prevalence of Functional Gastrointestinal Disorders in Colombian School Children. J Pediatr. 2014; 164(3):542-45. [ Links ]

2. Zwiener R, Robin S, Keller C, et al. Prevalence of Rome IV Functional Gastrointestinal Disorders in Children and Adolescents in the United States. Gastroenterology. 2017;152(5):S649. [ Links ]

3. Hyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2016:150:1456-68.e2. [ Links ]

4. Headache classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629-808. [ Links ]

5. Symon DN, Russell G. Double blind placebo controlled trial of pizotifen syrup in the treatment of abdominal migraine. Arch Dis Child. 1995;72:48-50. [ Links ]

Received: May 27, 2019; Accepted: September 28, 2019

Correspondence: Kathryn Hawa. E-mail: KathrynHawa@nationwidechildren.org.

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