Adam was born normally at term and had no neonatal problems. He has no fam­ily history of similar illnesses. His mother has menstrual migraine. His father and his 8-year-old brother are well and healthy.

triggered by intercurrent illnesses, long intervals between episodes and possibly a lack of awareness of the condition among clinical personnel.

Taking a thorough clinical history is crucial in assessing a child with CVS.Enquiry about all symptoms throughout the whole duration of the episodes will identify, as seen in the case of Adam above, the several phases of the CVS episode, the trigger factors, premonitory symptoms, associated symptoms, relieving factors, response to treatment and resolution of the episode and return to normal health (Fig.6.1).

The choice of investigations depends on the predominant symptoms during epi­sodes (Fig.6.2).

• Children presenting with abdominal pain, diarrhoea, constipation, food intoler-

ance and weight loss should be investigated with abdominal ultrasound, coeliac

• Neurological investigations with brain imaging are important if the child pres-

ents with seizures, new focal neurological decits, motor incoordination, person-

The earlier the treatment starts after the onset of symptoms the more successful the outcome will be. Children will be taught to recognise the early features of the pending or actual attack and also to inform parents or the adult carers of early symptoms. The child should be allowed to rest in a quiet room and monitored by an adult carer. The child will be given free access to uids to take small sips, paracetamol, if needed, and anti-emetic. Early administration of anti-emetic medications will help in relieving or reducing nausea and vomiting and also improve gastric emptying in order to allow reli­able oral rehydration. The choice of which anti-emetic drug to give depends on local availability, experience and licensing (Table 6.2) [23, 24]. Ondansetron is a 5-Hydroxytriptamin (5HT Other medications can also be used with caution in regard to possible adverse reactions such as cardiac arrhythmia and prolonged QT interval on electrocardiograph recording with chronic use of domperidone and extrapyramidal side effect with metoclopramide.

Children are advised to adopt a healthy lifestyle that reduces the risk and fre­quency of CVS.The advice includes a regular routine of getting enough sleep, eat­ing regular meals, exercising regularly and getting good rest in between. Children will be advised to monitor for specic triggers and try to avoid them as well as to reduce intake of caffeinated drinks and avoid smoking.

Amitriptyline, pizotifen and cyproheptadine are rst-line treatments for many children due to their relatively good response and safety prole, but may need to be avoided in overweight children as they may improve appetite and may lead to weight gain.

Propranolol, a beta-blocker, is an effective preventive treatment for migraine and was also shown to be useful for the prevention of CVS in children. Propranolol is administered orally in a dose of 1–2mg/kg, divided into two doses.

Other potential preventive treatments include unarizine, L-carnitine and coen­zyme Q10. The use of anti-epileptic drugs sodium valproate and topiramate is not recommended in girls and young women with child-bearing potential.

compared to children with irritable bowel syndrome and other organic gastrointes­tinal disorders [28]. Duration of episodes and missing school days were signi­cantly associated with lower scores by children. Delayed diagnosis and missing school days negatively impacted on parents’ scores [28].

It is estimated that in 24% of children with CVS, the condition resolves com­pletely by late adolescence and early adult life. In about 30% the disease continues and in 40–50% CVS will be replaced by migraine with or without aura [29].