Gut-Brain Interaction, the Overlapping Connection Between Cyclic Vomiting and Migraine

B U. K. Li, MD

Abdominal migraine is characterized as a syndrome that causes repetitive stereotypic episodes of paroxysmal abdominal pain, nausea and/or vomiting, and wellness between episodes.¹ This type of migraine overlaps with another condition called cyclic vomiting syndrome (CVS), which is also considered a central nervous system disorder. Thus, having more familiarity with the condition of CVS and its symptoms may help with efficacy at the time of diagnosis and may reduce morbidity.²

B U. K. Li, MD, emeritus professor of pediatrics and gastroenterology at the Medical College of Wisconsin, spoke in a plenary session on abdominal migraine and cyclical vomiting at the 2023 American Headache Society (AHS) Annual Meeting, June 15-18, in Austin, Texas. The session was titled, “’I Have a Gut Feeling’ Systemic Contributions to Headache,” and was focused on topics in the gastrointestinal (GI) system and diet among patients with migraine.

Li sat down in a recent interview with NeurologyLive® at the meeting to talk about his presentation, including his experience in the GI field, the years of research and patient observation, and what all of that taught him about the relationship between CVS and migraine. He also spoke about how programs can contribute to the management of CVS, and the factors that they can address beyond medication. In addition, he discussed the challenges that exist in finding effective treatments for the sensation of nausea in CVS, and the importance of collaboration with medical professionals in managing these conditions.

NeurologyLive®: What is a brief overview of your presentation on abdominal migraine and cycle vomiting?

B U. K. Li, MD: I have been involved with cyclic vomiting in the field for about 30 years. Over time from seeing over 1000 patients from all over, I found that there is a tremendous overlap with migraine headaches, abdominal migraine, and cyclic vomiting. Some of the kids that develop cyclic vomiting syndrome go on to also develop abdominal migraine and, as they become teenagers, develop migraine headaches. Some of them have all 3 of these conditions, and some occasionally have 2 or 3 of them at the same time with separate episodes of each of them. I've been impressed that there is clearly a relationship between CVS and migraine. For example, in my GI field, with CVS, we essentially use antimigraine approaches plus antivomiting approaches, but many of the things we use are borrowed from our neurology colleagues.

What would you say are the main takeaways from your research experience in this field?

Most of mine have been conducted in CVS rather than abdominal migraine. I've seen many more patients with cyclic vomiting than abdominal migraine. I don't really consider myself an expert in the latter, but I think one of the fascinating things about migraines in general is the number of GI symptoms: severe nausea, abdominal pain, vomiting, loss of appetite, and anorexia. Clearly, this has taught me over time that the brain and gut are tightly connected, and we have a term for that. Now, these disorders, including cyclic vomiting, and abdominal migraine are called disorders of gut-brain interaction, or DGBI. If I were a neurologist, it would be brain-gut interaction but because there's a GI classification, it's the other way around. But essentially, it's a cross talk between brain and gut in either case.

Taking it a step further, one of the things I observed earlier on in watching these pediatric patients is that they will often vomit at an average median and mean pace of about every 10 minutes, that is relentlessly. Almost nothing makes you vomit at that pace, not even food poisoning, stomach flu, or bowel obstruction. I noticed that once they empty the stomach, there should be no more drive to vomit, but they would continue retching every 10 minutes. That told me very early on, as I began to try to conceptualize what was going on, that the brain was the driver, and the gut was a follower in that instance.

What is there that we do about this condition for patients who experience these symptoms?

Well, we have no FDA approved drugs for CVS and largely we have borrowed from our neurology colleagues. I would say the overarching approach is very much like that in migraine that I've been involved in establishing several multidisciplinary programs to treat CVS. The programs included not only myself but neurologist or neurology nurse practitioner, psychologist, and nurses at Lurie Children's Hospital of Chicago and Children's Hospital of Wisconsin. This was necessary to try to address the whole patient. For example, we know that anxiety is a huge issue so, the psychologist addresses stress and we also address lifestyle issues including sleep, exercise, eating regularly, very much similar to migraine.

Medications are similarly used for migraine headaches.If there's enough of a warning phase, we will even use sumatriptan. But oftentimes they will break through, and the patients will sometimes have episodes every week. The consequences of this are that they're missing school because they're vomiting, getting dehydrated. We then have to go ahead and put them on preventative therapy, and many of those the same that neurologists use for migraine headaches. Those are tricyclic antidepressants like amitriptyline and in the younger patients cyproheptadine (Periactin). We will often use anticonvulsants, such as topiramate. In Japan, they tend to use valproic acid. The other approach is we use antiemetic medications, and one is on ondansetron (Zofran) used usually acutely. Another is aprepitant (Emend), which can be used to try to abort the attack, but also can be used to try to prevent it, that's probably something different than most neurologists would use.

Unfortunately, nausea is one of the principal symptoms in both migraine and CVS. Many of the patients like the older ones will tell us that nausea is sometimes worse even than the vomiting. There is no effective antinausea drug. There is one whole volume on nausea written by my colleague, Kenneth L. Koch, MD, about this. There are good medications for vomiting but not for the sensation of nausea and that may be because it's a very complex symptom.

Is there anything that you think potentially like neurologists should keep in mind when they have patients who are going through with this?

This is an interesting set of disorders because both cyclic vomiting and abdominal migraine can be taken care of, in at least my pediatric field, by either a pediatric neurologist or pediatric gastroenterologist. I think one of the take-home messages I'd like to pass on, in part of my presence at the American headache Society meeting, is that we need more collaboration both scientifically, clinically, and on guidelines. For example, our first guidelines on cyclic vomiting syndrome published in 2008, we had two pediatric neurologists on our task force to write those guidelines, including Donald Lewis, MD and Steven Linder, MD. That was precisely because so many of the things we use were migraine agents, and they obviously had much more experienced than we did. We are currently revising the guidelines and we also have pediatric neurologist on our committee, Amy Gelfand, MD. I think this is an example going forward that we need to solve these together because clearly the GI aspects of migraine are a big part of the migraine morbidity.

Transcript edited for clarity. Click here for more coverage of AHS 2023.

REFERENCES
1. Worawattanakul M, Rhoads JM, Lichtman SN, Ulshen MH. Abdominal migraine: prophylactic treatment and follow-up. J Pediatr Gastroenterol Nutr. 1999;28(1):37-40. doi:10.1097/00005176-199901000-00010
2. McAbee GN, Morse AM, Cook W, Tang V, Brosgol Y. Neurological Etiologies and Pathophysiology of Cyclic Vomiting Syndrome. Pediatr Neurol. 2020;106:4-9. doi:10.1016/j.pediatrneurol.2019.12.001