Abstract
Dear Sir I read with interest the paper of Galli et al. (1) entitled ‘Headache and recurrent abdominal pain: a controlled study by the means of the Child Behaviour Checklist (CBCL)’. They found that children and adolescents with headache or RAP show a very similar psychological profile, and it is proposed that the two conditions are closely related.
Between 4% and 25% of school age children complain of 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, without objective evidence of an underlying organic disorder.
Abdominal migraine is a rarely recognized pediatric functional gastrointestinal disorder, described in the Pediatric Rome II Criteria (2). However, also abdominal migraine is one of the variants of migraine headache typically occurring in children and coded within the group ‘Childhood periodic syndromes that are commonly precursors of migraine’. The affected children frequently develop typical migraine later in their life.
There is evidence to suggest that, in children, RAP occurring in the absence of headache may be a migrainous equivalent or an early expression of adult migraine (3–7). In this regard, we have performed a study during adolescence and young adulthood, in patients diagnosed of functional RAP in childhood, whose objective was to determine whether functional recurrent abdominal pain in pediatric age can predict gastrointestinal or extradigestive functional disorders, which seems to confirm those findings (8).
It is a retrospective longitudinal design of cases and controls. Symptoms-based diagnostic criteria (Roma II) were used to classify the patients with functional RAP between 1992–1998 in a Pediatric Gastroenterology Unit. The average time since discharge was 7.76 + 1.4 years. The control group (matched for age and sex with the case group) were patients recruited from a primary care centre who did not have RAP.
When former consent was obtained, we realized a telephone interview with a comprehensive questionnaire that evaluated the presence of pain, its characteristics, symptoms associated and repercussion in life quality. We take on board the International Headache Society diagnostic criteria for migraine. The survey was answered by parents barring if the patient/control age was older than 16 years. The study was approved by our Ethic Committee. We performed the statistic comparison with the Fischer exact test.
We studied 116 patients: 58 of 75 patients with functional RAP (77.3%), and 58 control subjects. The average of age was 16.2 + 3.16 and 16.4 + 3.4 years respectively (the age ranged from 11.3 to 22.6 years), and of them, 62% were female in both. From the RAP patients, 25 (43.1%) continued with abdominal pain (68% women) and 22 (37.9%) from the control group (77% women) (p > 0.05), although 10/25 in the cases group consider that pain is an important limitation for their quality of life, and only 3/22 in the control group (p = 0.056). Another symptoms compatible with functional gastrointestinal disorders were presented in 15/25 cases and 10/22 controls (p > 0.05).
They had migraine, respectively cases/controls: 18 (31%) vs. 8 (13.8%) (p < 0.05) (odds ratio 2.81; 95% confidence interval 1.2–6.3). We found that patients with previous pediatric functional RAP were significantly more likely than controls to suffer typical migraine headache during adolescence and young adulthood, which appear in nearly one third of those. Therefore, our data provide further evidence for a causal link and continuity between these two disorders.
The importance of clearly distinguishing abdominal migraine from other forms of RAP in childhood is emphasised, since a reasonable number of these patients could benefit from a prophylactic treatment of migraine (6, 9).