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A child in surrey with recurrent vomiting. | HeadPain Relief Centre

I recently had a case of the below condition & thought some of you may be interested in this relatively uncommon, but distressing type of migraine (note headache is only present in 40% & presentation is extremely variable !)

As always diagnosis by a specialist in headache & migraine is essential & other causes of recurrent vomiting must be definitively ruled out.

Once again I should stress the below is a brief summary only & there can be many subtly different ways in which the child/adolescent may present.

Migraine-associated cyclic vomiting syndrome (periodic syndrome)

This syndrome is characterized by recurrent periods of intense vomiting, at least 4 times per hour, separated by symptom-free intervals, with attacks occurring at least 1 week apart. Many patients with cyclic vomiting have regular or cyclic patterns of illness. Symptoms usually have a rapid onset at night or in the early morning and last at least 1 hour and up to 10 days (usually 6-48 hours). Associated symptoms include the following:

Abdominal pain – 80%

Nausea – 72%

Retching – 76%

Anorexia – 74%

Pallor – 87%

Lethargy – 91%

Photophobia – 32%

Phonophobia – 28%

Headache – 40%

Headache often does not appear until the child is older. Migraine-associated cyclic vomiting syndrome usually begins when the patient is a toddler and resolves in adolescence or early adulthood; it rarely begins in adulthood. More females than males are affected by cyclic vomiting.

Infections, psychological stress, physical stress, and dietary triggers are often clearly identified in the patient’s history. Examples of triggers include cheese, chocolate, monosodium glutamate (MSG), emotional stress, excitement, or infections. Usually, the parents or siblings have a family history of migraine.

Cyclic vomiting syndrome is a diagnosis of exclusion. It is important to differentiate cyclic vomiting related to migraine from nonmigraine cyclic vomiting conditions. Other causes of cyclic vomiting include the following:

GI disorders (malrotation)

Neoplasms

Urinary tract disorders

Metabolic and endocrine disorders

Mitochondrial deoxyribonucleic acid (DNA) deletions

Children with cyclic vomiting associated with migraine tend to experience fewer severe vomiting episodes per hour and fewer attacks per month than those with cyclic vomiting associated with other GI disorders. These children exhibit a higher incidence of pallor, abdominal pain, headache, social withdrawal, motion sickness, photophobia, and physical exhaustion.

Cyclic vomiting associated with developmental delay, poor growth, seizures, and maternal migraine may be associated with mutations of mitochondrial DNA. When such mutations are suggested, serum lactate/pyruvate and urine organic acid levels should be obtained, preferably during an attack.

Treatment.

Assuming other causes of cyclical vomiting have been ruled out treatment of this migraine ‘syndrome’ needs to be tailored to the individual child ; managed by specialists such as those here at Epsom and Ewell headache & migraine clinic

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