“My 8-year-old keeps getting episodes of severe tummy pain with sickness and pallor — then she’s completely fine. Tests are normal”

ABDOMINAL MIGRAINE is a recognised paediatric variant of migraine: recurrent, STEREOTYPED episodes of moderate-to-severe MIDLINE/central abdominal pain lasting hours (ICHD-3, international: 2–72 hours untreated; Rome IV, international: at least 1 hour) with associated PALLOR, nausea/vomiting, anorexia and lethargy, and — crucially — COMPLETE wellness between episodes with normal growth, often with a personal/family history of migraine, typically resolving or evolving into typical migraine in later childhood/adolescence. It is largely a CLINICAL diagnosis of EXCLUSION, made after history/examination and exclusion of red flags and other causes — which is why investigations are normal: normal tests SUPPORT rather than undermine the diagnosis, and explaining this prevents the family feeling nothing has been found. Screen the RED FLAGS (Rome IV alarm features) that would not fit abdominal migraine: weight loss/faltering growth, pain or vomiting waking the child from sleep/nocturnal symptoms, bilious vomiting (an emergency — possible malrotation/obstruction) or persistent vomiting, GI bleeding, chronic severe diarrhoea, fever, persistent right-sided/localised pain, abnormal examination, dysuria, joint/perianal/systemic features, family history of IBD, or symptoms between attacks — any of which warrant assessment/investigation. On the telephone, arrange a face-to-face review to examine her, plot growth and test urine. Consider the differential for recurrent paediatric abdominal pain (constipation, UTI, coeliac disease, inflammatory bowel disease, surgical causes such as intermittent obstruction/intussusception, intermittent pelviureteric junction obstruction, cyclical vomiting syndrome, mesenteric adenitis, and functional abdominal pain/IBS) and use appropriate basic tests (coeliac serology per NICE NG20, urine per NICE NG224; constipation per NICE CG99) to exclude. Manage with reassurance and clear explanation (a real form of migraine, not "nothing"), trigger identification/avoidance (stress, sleep, food, dehydration), lifestyle measures, acute symptomatic treatment (rest in a quiet dark room, early paracetamol or ibuprofen per BNFC, hydration; antiemetics are not routine at this age — domperidone not licensed under 12, MHRA December 2019; metoclopramide restricted in under-18s, MHRA August 2013 — and triptans are not licensed at 8), a symptom diary, and paediatric referral for frequent or severe episodes (preventive medicines are a specialist decision). The skill is recognising the stereotyped episodic pattern with symptom-free intervals, explaining why normal tests fit, excluding red flags, and managing/reassuring — not endless re-investigation.