Abdominal Migraine in a Middle-Aged Woman

□ CASE REPORT □ Abdominal Migraine in a Middle-aged Woman Yosuke Kunishi 1,YuriIwata1, Mitsuyasu Ota 2, Yuichi Kurakami 2, Mao Matsubayashi 1, Masatomo Kanno 1, Yoriko Kuboi 1, Koichiro Yoshie 2 and Yoshio Kato 1 Abstract 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 consid- ered as a cause of abdominal pain as it might easily be relieved by appropriate treatment. Key words: abdominal migraine, abdominal pain, adult, unknown origin (Intern Med 55: 2793-2798, 2016) (DOI: 10.2169/internalmedicine.55.6626) approximately half a day. Three months prior to presenta- Introduction tion, she visited our hospital’s emergency department for a fever, diarrhea, and vomiting. At the time, she was diag- Abdominal pain is one of the most common complaints nosed with infectious enteritis. Symptomatic treatment led to during outpatient examinations. In particular, due to recent recovery in approximately 3 days. Three weeks prior to developments in diagnostic imaging, imaging tests are fre- presentation, she had experienced abdominal pain accompa- quently performed in patients with complaints of abdominal nied by nausea and vomiting that lasted for approximately pain. Many cases in which abnormal findings are not ob- half a day, but she had spontaneous remission. However, one served are treated as cases of functional dyspepsia (FD), ir- week prior to presentation, she had experienced the same ritable bowel syndrome (IBS) and other functional gastroin- symptoms again and was seen by a local physician 5 days testinal disorders, or psychiatric disorders. We herein report prior to presenting at our hospital. She was diagnosed with a case of a middle-aged woman who was examined as an enteritis and prescribed medications: a proton pump inhibi- outpatient for complaints of repeated abdominal pain; she tor (lansoprazole), an intestinal regulator (bifidobacteria pro- was diagnosed with abdominal migraine as a result of a de- biotic), and Chinese herbal medicine (daikenchuto), but she tailed medical interview and showed a dramatic improve- subsequently experienced repeated abdominal pain that ment of her symptoms after the administration of medica- lasted for approximately half a day and was thus examined tions. Although there are very few reports on abdominal mi- at our department. The pain was located in the central por- graine occurring in adults, it is possible that many individu- tion of the trunk from the epigastric fossa to the lower abdo- als remain undiagnosed. Thus, we present this report be- men, with no bias toward either the right or left side. The cause we believe that our experience of and findings on this physical range of the pain was slightly indistinct. The pain condition are significant. was dull, and the most frequently experienced concomitant symptoms were poor appetite, nausea, and vomiting. The Case Report pain was not associated with prodromal symptoms, scintillating scotoma, or sensitivity to light or sound, and the pa- A 52-year-old woman presented at our outpatient depart- tient did not experience constipation, diarrhea, or weight ment with complaints of abdominal pain that persisted for loss. The pain was continuous and although it was severe １Department of Gastroenterology, Kanagawa Prefectural Ashigarakami Hospital, Japan and ２Department of Internal Medicine, Kanagawa Prefec- tural Ashigarakami Hospital, Japan Received for publication September 29, 2015; Accepted for publication December 8, 2015 Correspondence to Dr. Yosuke Kunishi, [email protected] 2793 Intern Med 55: 2793-2798, 2016 DOI: 10.2169/internalmedicine.55.6626 Table 1. Blood Test. and analgesics (loxoprofen as needed, 60 mg per use) for a Peripheral Blood Blood Chemistry few days, the abdominal pain disappeared along with the WBC 4,500 /ȝL TP 7.4 mg/dL CPK 69 mg/dL headache symptoms. Loxoprofen was tapered over the Neu 53 % Alb 4.5 mg/dL BUN 15.1 mg/dL course of 2 weeks and she eventually used lomerizine alone Eos 1 % AST 20 U/L Cr 0.6 mg/dL (Fig. 2). The symptoms initially appeared to recur when Lym 41 % ALT 12 U/L Na 140 mEq/L lomerizine was stopped, but after 6 months of continuous Mono 4 % LDH 187 U/L K 4.0 mEq/L lomerizine therapy, her abdominal pain completely disap- RBC 442×104 /ȝL ALP 198 U/L Cl 103 mEq/L peared and lomerizine was therefore stopped. Although she Hb 14.2 g/dL T-Bil 1.2 mg/dL Ca 10.2 mg/dL still experiences some occasional migraine headaches, they Ht 42.3 % AMY 157 U/L CRP 0.02 mg/dL are being well controlled by occasional loxoprofen use, and Plt 15.7×104 /ȝL Lipase 35.7 U/L there have been no episodes of abdominal pain. FBS 107 mg/dL Discussion enough to prevent her from performing housework, the Abdominal migraine falls under the subcategory of child- symptoms disappeared during intervals of no pain. She had hood periodic syndromes in the ICHD-II (1) and is classi- a history of migraine since 30 years of age and had under- fied as a childhood functional gastrointestinal disorder in the gone an ectopic pregnancy (surgery) at 32 years of age. Her Rome III critera (2). Both of these have established diagnos- family medical history indicated that both her mother and tic criteria for the disorder. Both consider abdominal mi- younger brother had migraines. She experienced menopause graine to be a childhood disorder with the average age of at 46 years of age and had no history of alcoholic beverage onset at 8 years and a relatively high prevalence rate be- consumption or smoking. tween 1% and 4% of children (3). It has a relatively good The physical findings were as follows: temperature, prognosis because most patients with childhood onset of ab- 36.6℃; blood pressure, 122/73 mmHg; heart rate, 74/min; dominal migraine go into spontaneous remission by the time and respiratory rate, 18/min. Her abdomen was flat and pli- they reach adulthood. However, although abdominal pain able, and although she reported pressure pain in the area ex- goes into remission, it shifts to a conventional migraine tending from the epigastric fossa to the lower abdomen, headache in many cases. Dignan et al. observed patients there was neither rebound tenderness nor muscular defense. with abdominal migraine for 10 years and reported that it Blood tests showed slightly elevated amylase levels, but shifted to migraine headache in 70% of them (4). Although no other abnormalities (Table 1). this disease is referred to as “abdominal migraine,” the Although several imaging modalities were performed (ab- headache is absent or mild in most cases (5). It is consid- dominal ultrasound, abdominal contrast-enhanced CT, and ered to be a migraine-related disorder for the following rea- upper and lower endoscopy), none showed abdominal find- sons: 1) a notable family history of migraine, 2) in many ings that indicated any of the above disorders (all imaging cases, the disorder shifts to migraine headache after reaching tests, except for lower endoscopy, were performed while the adulthood, 3) predominance in women, 4) a relatively patient was experiencing pain). Serological testing for im- clearly-defined beginning and end of symptoms, and 5) in munoglobulin G (IgG) antibodies of H. pylori was negative. many cases, migraine medication is effective. Abdominal We suspected a functional disorder such as FD, and admin- pain occurs in a poorly localized central abdominal area (6) istered pharmaceuticals; a stomachic (oxethazaine), an intes- and is often accompanied by concomitant symptoms such as tinal regulator (dimeticone), and an antiemetic (domperi- nausea and vomiting, which are observed in cases of con- done). However, because there was no improvement in her ventional migraine headaches. However, it is rarely associ- symptoms and the pain recurred several times, the patient ated with prodromal symptoms, scintillating scotoma, or was examined three times as an outpatient during the week sensitivity to light or sound. following her initial examination. During the third examina- In the present case, the pain experienced by this patient tion, she complained of a unilateral, throbbing headache in met the diagnostic criteria for abdominal migraine listed in addition to her abdominal symptoms. Her medical history both the ICHD-II and the Rome III criteria. However, a suggested that the cause of the headache to be a migraine; careful workup through the differential diagnosis was re- however, on reviewing her abdominal pain history, we dis- quired because the duration of the interval between attacks covered that it was marked by paroxysmal onset and went was atypical, there have been few reports on this disorder into spontaneous remission after approximately 12 hours of occurring in adults (7-13), and it is a functional disorder. continuous pain. Both the location of the abdominal pain Many patients who complain of epigastric symptoms dur- and the concomitant symptoms met the diagnostic standards ing outpatient exams and who cannot be diagnosed by imag- for the International Classification of Headache Disorders, ing tests are treated for FD. The present case was also 2nd Edition (ICHD-II) (1) and the Rome III criteria (2) for treated for FD, but showed no signs of improvement. Using abdominal migraine (Fig. 1). After administering calcium the Rome III criteria (14), except for the fact that the ab- blockers (lomerizine, 10 mg/day, as prophylactic treatment) dominal pain lasted for a short time, the patient’s symptoms 2794 Intern Med 55: 2793-2798, 2016 DOI: 10.2169/internalmedicine.55.6626 Diagnostic criteria of abdominal migraine Diagnostic criteria of abdominal migraine (ICHD-II) (Rome III) A.

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