Abdominal migraine

Midline abdominal pain with paroxysmal, recurrent, acute onset attacks that last an average of 17 hours are the hallmarks of abdominal migraine.{{cite journal | last1=Evans | first1=Randolph W. | last2=Whyte | first2=Chad | title=Cyclic Vomiting Syndrome and Abdominal Migraine in Adults and Children | journal=Headache: The Journal of Head and Face Pain | publisher=Wiley | volume=53 | issue=6 | date=May 30, 2013 | issn=0017-8748 | doi=10.1111/head.12124 | pages=984–993| pmid=23721241 | s2cid=205159221 }} There have been reports that these attacks can last anywhere from two to seventy-two hours. Although it has also been reported to be diffuse and colicky, the pain is usually described as dull and periumbilical. 91% of patients have anorexia, 73% to 91% have nausea, 35% to 50% vomit, and 93% to 100% of patients have associated pallor.{{cite journal | last1=Irwin | first1=Samantha | last2=Barmherzig | first2=Rebecca | last3=Gelfand | first3=Amy | title=Recurrent Gastrointestinal Disturbance: Abdominal Migraine and Cyclic Vomiting Syndrome | journal=Current Neurology and Neuroscience Reports | publisher=Springer Science and Business Media LLC | volume=17 | issue=3 | year=2017 | issn=1528-4042 | doi=10.1007/s11910-017-0731-4 | page=21| pmid=28283964 | s2cid=4458523 }} The attack usually comes to an abrupt end. The average annual frequency of abdominal migraine attacks in patients is 14.

Although nonspecific prodromes can occur before attacks, abdominal migraine attacks are usually sporadic. This can include behavioral and mood swings, anorexia, flushing, diarrhea, and auras that include numbness, slurred speech, tingling in the distal extremities, and flashing lights. Weeks to months may pass between episodes, and during this time patients usually experience no symptoms.{{cite journal | last1=Cervellin | first1=Gianfranco | last2=Lippi | first2=Giuseppe | title=Abdominal migraine in the differential diagnosis of acute abdominal pain | journal=The American Journal of Emergency Medicine | publisher=Elsevier BV | volume=33 | issue=6 | year=2015 | issn=0735-6757 | doi=10.1016/j.ajem.2014.12.066 | pages=864.e3–864.e5| pmid=25616589 }}

Abdominal migraine has been linked to specific alterations in the gut-brain axis, vascular dysregulation, modifications in the central nervous system, and genetic factors.{{cite journal | last=Angus-Leppan | first=Heather | title=Migraine: mimics, borderlands and chameleons | journal=Practical Neurology | publisher=BMJ | volume=13 | issue=5 | date=August 1, 2013 | issn=1474-7758 | doi=10.1136/practneurol-2012-000502 | pages=308–318| pmid=23906594 | s2cid=33590756 }}

Abdominal migraine pathophysiology may involve psychological factors. Abuse and stressful events are two risk factors for recurrent abdominal pain, for instance. Furthermore, it has been demonstrated that kids with functional gastrointestinal disorders experience mental health conditions like anxiety and depression more frequently than kids without these conditions.{{cite journal | last1=Devanarayana | first1=N. M. | last2=Rajindrajith | first2=S. | last3=Perera | first3=M. S. | last4=Nishanthanie | first4=S. W. | last5=Karunanayake | first5=A. | last6=Benninga | first6=M. A. | title=Association Between Functional Gastrointestinal Diseases and Exposure to Abuse in Teenagers | journal=Journal of Tropical Pediatrics | publisher=Oxford University Press (OUP) | volume=60 | issue=5 | date=July 23, 2014 | issn=0142-6338 | doi=10.1093/tropej/fmu035 | pages=386–392| pmid=25059210 }}

There are several typical causes of attacks of abdominal migraines. Stressors related to work and family life, irregular sleep patterns, extended fasts and food deprivation, dehydration, exercise, travel, high-amine foods, foods containing flavoring, coloring, and monosodium glutamate (MSG), and flashing lights are a few common triggers.

A significant hereditary component may be involved in abdominal and other migraines due to their strong familial incidence,{{cite journal | last1=Sutherland | first1=Heidi G. | last2=Griffiths | first2=Lyn R. | title=Genetics of Migraine: Insights into the Molecular Basis of Migraine Disorders | journal=Headache: The Journal of Head and Face Pain | volume=57 | issue=4 | date=2017 | issn=0017-8748 | doi=10.1111/head.13053 | pages=537–569| pmid=28271496 | s2cid=40801526 |url=https://eprints.qut.edu.au/105633/1/Sutherland_2017_JHFP.pdf }} especially in the case of mutations affecting cell membrane transport (channelopathies).{{cite journal | last1=Giffin | first1=N J | last2=Benton | first2=S | last3=Goadsby | first3=P J | title=Benign paroxysmal torticollis of infancy: four new cases and linkage to CACNA1A mutation | journal=Developmental Medicine & Child Neurology | publisher=Wiley | volume=44 | issue=7 | year=2002 | pages=490–493 | issn=0012-1622 | doi=10.1017/s0012162201002407 | doi-broken-date=5 January 2025 | doi-access=free| pmid=12162387 }}{{cite journal | last1=DALE | first1=RUSSELL C | last2=GARDINER | first2=ALICE | last3=ANTONY | first3=JAYNE | last4=HOULDEN | first4=HENRY | title=Familial PRRT2 mutation with heterogeneous paroxysmal disorders including paroxysmal torticollis and hemiplegic migraine | journal=Developmental Medicine & Child Neurology | publisher=Wiley | volume=54 | issue=10 | date=July 31, 2012 | issn=0012-1622 | doi=10.1111/j.1469-8749.2012.04394.x | pages=958–960 | doi-access=free| pmid=22845787 }}

While the pathophysiology of functional gastrointestinal disorders (FGIDs) has many potential contributors, the etiology of abdominal migraine is still unknown.{{cite journal | last1=Azmy | first1=Demiana J. | last2=Qualia | first2=Cary M. | title=Review of Abdominal Migraine in Children | journal=Gastroenterology & Hepatology | publisher=Millenium Medical Publishing | volume=16 | issue=12 | date=November 30, 2018 | pages=632–639 | pmid=34035698 | pmc=8132691 }}

It is thought that abnormal electrical discharge from the hypothalamus that travels to the cortex and autonomic nervous system{{cite journal | last1=Mortimer | first1=M.J. | last2=Good | first2=P.A. | title=The VER as a Diagnostic Marker for Childhood Abdominal Migraine | journal=Headache: The Journal of Head and Face Pain | publisher=Wiley | volume=30 | issue=10 | year=1990 | issn=0017-8748 | doi=10.1111/j.1526-4610.1990.hed3010642.x | pages=642–645| pmid=2272813 | s2cid=27579213 }} or variations in the cerebral artery's blood flow velocity cause attacks.{{cite journal | last=Good | first=Peter A. | title=Neurologic Investigations of Childhood Abdominal Migraine: A Combined Electrophysiologic Approach to Diagnosis | journal=Journal of Pediatric Gastroenterology and Nutrition | publisher=Wiley | volume=21 | year=1995 | issn=0277-2116 | doi=10.1097/00005176-199501001-00013 | pages=S44–S48| pmid=8708868 }} In patients with FGIDs, there appears to be a disruption in the complex brain-gut axis.{{cite journal | last1=Weydert | first1=Joy A. | last2=Ball | first2=Thomas M. | last3=Davis | first3=Melinda F. | title=Systematic Review of Treatments for Recurrent Abdominal Pain | journal=Pediatrics | publisher=American Academy of Pediatrics (AAP) | volume=111 | issue=1 | date=January 1, 2003 | issn=0031-4005 | doi=10.1542/peds.111.1.e1 | pages=e1–e11| pmid=12509588 }} Many episodic functional gastrointestinal disorders in childhood have been linked to mitochondrial disease,{{cite journal | last1=Boles | first1=R. G. | last2=Zaki | first2=E. A. | last3=Lavenbarg | first3=T. | last4=Hejazi | first4=R. | last5=Foran | first5=P. | last6=Freeborn | first6=J. | last7=Trilokekar | first7=S. | last8=Mccallum | first8=R. | title=Are pediatric and adult-onset cyclic vomiting syndrome (CVS) biologically different conditions? Relationship of adult-onset CVS with the migraine and pediatric CVS-associated common mtDNA polymorphisms 16519T and 3010A | journal=Neurogastroenterology & Motility | publisher=Wiley | volume=21 | issue=9 | date=August 5, 2009 | pages=936–e72 | issn=1350-1925 | doi=10.1111/j.1365-2982.2009.01305.x | pmid=19368653 | s2cid=43046971 }} hypothalamic-pituitary-axis dysfunction, and gene mutations; these associations have not, however, been studied in patients diagnosed with abdominal migraine.{{cite journal | last1=Napthali | first1=Kate | last2=Koloski | first2=Natasha | last3=Talley | first3=Nicholas J | title=Abdominal migraine | journal=Cephalalgia | volume=36 | issue=10 | date=2016 | issn=0333-1024 | doi=10.1177/0333102415617748 | pages=980–986| pmid=26582952 | s2cid=23764515 }}

{{howto|date=August 2024}}

It's critical to rule out organic diseases as the source of a child's symptoms while also taking the patient's functional state into account. When diagnosing abdominal migraine, a patient's complete medical history and physical examination are crucial. Additionally, any potential alarm signs and symptoms should be carefully examined. The presence of visible or occult blood in the stool, dysphagia, hematemesis, bilious vomiting, fever, changes in growth pattern, and weight loss are a few examples of alarm symptoms.{{cite journal | last1=Di Lorenzo | first1=Carlo | last2=Colletti | first2=Richard B | last3=Lehmann | first3=Horald P | last4=Boyle | first4=John T | last5=Gerson | first5=William T | last6=Hyams | first6=Jeffrey S | last7=Squires | first7=Robert H | last8=Walker | first8=Lynn S | last9=Kanda | first9=Pamela T | title=Chronic Abdominal Pain In Children: A Technical Report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition | journal=Journal of Pediatric Gastroenterology & Nutrition | publisher=Wiley | volume=40 | issue=3 | year=2005 | issn=0277-2116 | doi=10.1097/01.mpg.0000154661.39488.ac | pages=249–261| pmid=15735476 }} Further imaging and testing should be carried out if these alarm signs or symptoms are apparent.{{cite journal | last1=McFerron | first1=Brian A. | last2=Waseem | first2=Shamaila | title=Chronic Recurrent Abdominal Pain | journal=Pediatrics in Review | publisher=American Academy of Pediatrics (AAP) | volume=33 | issue=11 | date=November 1, 2012 | issn=0191-9601 | doi=10.1542/pir.33.11.509 | pages=509–517| pmid=23118316 }}

The Rome IV criteria state that paroxysmal bouts of intense, acute periumbilical, midline, or diffuse abdominal pain lasting at least an hour, exhibiting a recurrent pattern, being incapacitating, and interfering with regular activities can be used to diagnose abdominal migraine if at least two of these episodes take place over a six-month period. There should be weeks or months without any symptoms in between attacks. The following symptoms must be present in at least two instances: pallor, photophobia, headache, nausea, vomiting, and anorexia. Lastly, there is no other medical diagnosis that can account for the symptoms.{{cite web | title=Rome IV Criteria | website=Rome Foundation | date=March 6, 2023 |url=https://theromefoundation.org/rome-iv/rome-iv-criteria/ | access-date=December 31, 2023}}

Abdominal migraine is defined by the International Classification of Headache Disorders III criteria as five or more episodes of abdominal pain lasting two to seventy-two hours. A minimum of two out of three of the following criteria must also be met by the pain: dull or "just sore" quality; midline location, periumbilical, or poorly localized; and moderate to severe intensity. Pallor, nausea, vomiting, and anorexia are associated symptoms that the patient should have at least two of.

Abdominal migraine must be distinguished from other causes of chronic or recurrent abdominal pain. These include irritable bowel syndrome, peptic ulcer disease, and gastroesophageal reflux disease. It must also be distinguished from causes of acute abdominal pain, such as appendicitis, as wrong diagnosis may lead to unnecessary appendectomy.

Because there are so few studies in the literature, there are no firm recommendations for the treatment of abdominal migraines.{{cite journal | last=Lundberg | first=P. O. | title=Abdominal Migraine-Diagnosis and Therapy | journal=Headache: The Journal of Head and Face Pain | publisher=Wiley | volume=15 | issue=2 | year=1975 | issn=0017-8748 | doi=10.1111/j.1526-4610.1975.hed1502122.x | pages=122–125| pmid=1150428 | s2cid=23179583 }} The majority of treatment options are predicated on anecdotal evidence, a small number of studies conducted on a relatively small number of children, and a close correlation between abdominal migraines and both migraine headaches and FGIDs.{{cite journal | last1=Worawattanakul | first1=Mingmuang | last2=Rhoads | first2=J. Marc | last3=Lichtman | first3=Steven N. | last4=Ulshen | first4=Martin H. | title=Abdominal Migraine: Prophylactic Treatment and Follow-up | journal=Journal of Pediatric Gastroenterology & Nutrition | publisher=Wiley | volume=28 | issue=1 | year=1999 | issn=0277-2116 | doi=10.1097/00005176-199901000-00010 | pages=37–40| pmid=9890466 }}

When treating patients with abdominal migraines, doctors may find the STRESS mnemonic useful. It stands for stress management, travel advice, rest, emergency symptoms, sparkling lights, and snacks to avoid.{{cite journal | last1=Catala-Beauchamp | first1=Aixa I. | last2=Gleason | first2=Robyn P. | title=Abdominal Migraine in Children: Is It All in Their Heads? | journal=The Journal for Nurse Practitioners | publisher=Elsevier BV | volume=8 | issue=1 | year=2012 | issn=1555-4155 | doi=10.1016/j.nurpra.2011.06.007 | pages=19–26}}

Certain triggers, like bright light, restless nights, travel, and extended fasting, should probably be minimized or avoided once they have been identified. Emotional stressors from family or school activities can be a trigger for certain kids, so it's best to minimize or stay away from them. Although there are no particular randomized trials evaluating the efficacy of biofeedback and counselling in treating abdominal migraines, it is believed that these interventions may be helpful if emotional stress is a trigger factor in the development of migraine in children.{{cite journal | last1=Blume | first1=Heidi K. | last2=Brockman | first2=Libby N. | last3=Breuner | first3=Cora C. | title=Biofeedback Therapy for Pediatric Headache: Factors Associated With Response | journal=Headache: The Journal of Head and Face Pain | publisher=Wiley | volume=52 | issue=9 | date=July 13, 2012 | issn=0017-8748 | doi=10.1111/j.1526-4610.2012.02215.x | pages=1377–1386| pmid=22804229 | s2cid=23605499 }}

It's unclear what function elimination diets serve. Nonetheless, in patients experiencing both migraine and IBS symptoms, an immunoglobulin G (IgG)-based elimination diet shows promise in lowering migraine episodes.{{cite journal | last1=Aydinlar | first1=Elif Ilgaz | last2=Dikmen | first2=Pinar Yalinay | last3=Tiftikci | first3=Arzu | last4=Saruc | first4=Murat | last5=Aksu | first5=Muge | last6=Gunsoy | first6=Hulya G. | last7=Tozun | first7=Nurdan | title=IgG-Based Elimination Diet in Migraine Plus Irritable Bowel Syndrome | journal=Headache: The Journal of Head and Face Pain | publisher=Wiley | volume=53 | issue=3 | date=December 6, 2012 | issn=0017-8748 | doi=10.1111/j.1526-4610.2012.02296.x | pages=514–525| pmid=23216231 | s2cid=34736265 }} There isn't much more proof that a child's diet has a significant impact on when migraines begin.{{cite journal | last=Gelfand | first=Amy A. | title=Migraine and childhood periodic syndromes in children and adolescents | journal=Current Opinion in Neurology | publisher=Ovid Technologies (Wolters Kluwer Health) | volume=26 | issue=3 | year=2013 | issn=1350-7540 | doi=10.1097/wco.0b013e32836085c7 | pages=262–268| pmid=23549418 }}

In one study, 14 children with abdominal migraine were administered pizotifen syrup, a serotonin and histamine antagonist. After four months, 70% of the patients said their symptoms had improved. Their symptoms were noticeably milder and less frequent.{{cite journal | last1=Symon | first1=D N | last2=Russell | first2=G | title=Double blind placebo controlled trial of pizotifen syrup in the treatment of abdominal migraine. | journal=Archives of Disease in Childhood | publisher=BMJ | volume=72 | issue=1 | date=January 1, 1995 | issn=0003-9888 | doi=10.1136/adc.72.1.48 | pages=48–50| pmid=7717738 | pmc=1510964 }} Propranolol and cyproheptadine syrup were found to alleviate symptoms in a retrospective review. Flunarizine use was found to reduce the frequency and duration of abdominal migraine attacks in another retrospective review.{{cite journal | last=Kothare | first=Sanjeev V. | title=Efficacy of flunarizine in the prophylaxis of cyclical vomiting syndrome and abdominal migraine | journal=European Journal of Paediatric Neurology | publisher=Elsevier BV | volume=9 | issue=1 | year=2005 | issn=1090-3798 | doi=10.1016/j.ejpn.2004.11.002 | pages=23–26| pmid=15701563 }}

Analgesics, triptans, and antiemetics may be helpful for sudden attacks of abdominal migraines. It has been suggested that patients with nausea, vomiting, or anorexia might benefit more from nasal sprays or suppositories. Acute attacks have been reported to be resolved by acetaminophen and ibuprofen.{{cite journal | last1=Lewis | first1=Donald W | last2=Yonker | first2=Marcy | last3=Winner | first3=Paul | last4=Sowell | first4=Michael | title=The Treatment of Pediatric Migraine | journal=Pediatric Annals | publisher=SLACK, Inc. | volume=34 | issue=6 | year=2005 | issn=0090-4481 | doi=10.3928/0090-4481-20050601-10 | pages=448–460| pmid=16018227 }} Intranasal sumatriptan alleviated the symptoms of abdominal migraine in two children, according to a case report.{{cite journal | last1=Kakisaka | first1=Yosuke | last2=Wakusawa | first2=Keisuke | last3=Haginoya | first3=Kazuhiro | last4=Saito | first4=Akiko | last5=Uematsu | first5=Mitsugu | last6=Yokoyama | first6=Hiroyuki | last7=Sato | first7=Tetsuo | last8=Tsuchiya | first8=Shigeru | title=Efficacy of Sumatriptan in Two Pediatric Cases With Abdominal Pain-Related Functional Gastrointestinal Disorders: Does the Mechanism Overlap That of Migraine? | journal=Journal of Child Neurology | publisher=SAGE Publications | volume=25 | issue=2 | date=June 9, 2009 | issn=0883-0738 | doi=10.1177/0883073809336875 | pages=234–237| pmid=19509407 | s2cid=41114159 }} In refractory cases, intravenous sodium valproate has been reported to resolve abdominal migraine episodes.{{cite journal | last1=Tan | first1=Violeta | last2=Revelo Sahami | first2=Alcira | last3=Peebles | first3=Rebecka | last4=Shaw | first4=Richard J. | title=Abdominal Migraine and Treatment With Intravenous Valproic Acid | journal=Psychosomatics | publisher=Elsevier BV | volume=47 | issue=4 | year=2006 | issn=0033-3182 | doi=10.1176/appi.psy.47.4.353 | pages=353–355| pmid=16844896 }} According to a case series, intravenous dihydroergotamine treatment prevented abdominal migraine attacks in five out of six pediatric patients.{{cite journal | last1=Raina | first1=Madiha | last2=Chelimsky | first2=Gisela | last3=Chelimsky | first3=Thomas | title=Intravenous Dihydroergotamine Therapy for Pediatric Abdominal Migraines | journal=Clinical Pediatrics | publisher=SAGE Publications | volume=52 | issue=10 | date=July 1, 2013 | issn=0009-9228 | doi=10.1177/0009922813492879 | pages=918–921| pmid=23820001 | s2cid=206405642 }}

Abdominal migraine can have a significant impact on day-to-day life.{{cite journal|last=Catto-Smith|first=AG|author2=Ranuh, R|date=Nov 2003|title=Abdominal migraine and cyclical vomiting.|journal=Seminars in Pediatric Surgery|volume=12|issue=4|pages=254–8|doi=10.1053/j.sempedsurg.2003.08.006|pmid=14655164}} Children may miss school or other activities. It resolves in many patients.{{Cite journal|last1=Angus-Leppan|first1=Heather|last2=Saatci|first2=Defne|last3=Sutcliffe|first3=Alastair|last4=Guiloff|first4=Roberto J.|date=19 February 2018|title=Abdominal migraine|url=https://www.bmj.com/content/360/bmj.k179|journal=British Medical Journal|language=en|volume=360|pages=k179|doi=10.1136/bmj.k179|issn=0959-8138|pmid=29459383|s2cid=5256538 }}{{Cite journal |last1=Napthali |first1=Kate |last2=Koloski |first2=Natasha |last3=Talley |first3=Nicholas J |date=2016-07-19 |title=Abdominal migraine |url=https://journals.sagepub.com/doi/10.1177/0333102415617748 |journal=Cephalalgia |volume=36 |issue=10 |pages=980–986 |doi=10.1177/0333102415617748 |pmid=26582952 |s2cid=23764515 |issn=0333-1024}}

Abdominal migraine primarily affects children, for whom it is a common cause of chronic abdominal pain. It may be as high as 9% or as low as 1% among children. It is rare in adults. However, children diagnosed with abdominal migraines may have migraine headaches as adults.{{cite journal|date=April 2016|title=Headache: Hope through research|url=https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Hope-Through-Research/Headache-Hope-Through-Research|journal=NINDS}} The mean age of diagnosis is 7 years.Evans RW, Whyte C. Cyclic vomiting syndrome and abdominal migraine in adults and children. Headache. 2013;53:984–993Monteferrante, Nikolas, Ho, Jacquelyn, Wilhelmi, Brian, MD, JD, Uribe, Juan. Prevention of Perioperative Abdominal Migraine in a Patient Undergoing Spinal Fusion: A Case Report. A A Pract. 2021;15(6):e01484. doi:10.1213/XAA.0000000000001484. It appears to be slightly more common in women.

This condition was first described in 1921 by Buchanan.{{cite book|editor-last=Tepper|editor-first=Stewart J.|editor-last2=Tepper|editor-first2=Deborah E.|title=The Cleveland Clinic manual of headache therapy|publisher=Springer|location=New York|isbn=9781461401780|pages=96|url=https://books.google.com/books?id=uaG08nAKG_wC&pg=PA96|date=2011-08-22}} It was once considered a controversial diagnosis.{{cite book|last=Davidoff|first=Robert A.|url=https://books.google.com/books?id=PAdn6xC3KlAC&pg=PA81|title=Migraine : manifestations, pathogenesis, and management|publisher=Oxford Univ. Press|year=2002|isbn=9780195137057|edition=2nd|location=Oxford [u.a.]|page=81}} However, it is now accepted as a common cause of chronic abdominal pain in children.{{Cite journal|last1=Mani|first1=Jyoti|last2=Madani|first2=Shailender|date=2018-04-24|title=Pediatric abdominal migraine: current perspectives on a lesser known entity|journal=Pediatric Health, Medicine and Therapeutics|volume=9|pages=47–58|doi=10.2147/PHMT.S127210|issn=1179-9927|pmc=5923275|pmid=29733088 |doi-access=free }}

• Migraine
• Functional gastrointestinal disorder

{{reflist}}

• {{cite journal | last1=Abu-Arafeh | first1=I | last2=Russell | first2=G | title=Prevalence and clinical features of abdominal migraine compared with those of migraine headache. | journal=Archives of Disease in Childhood | publisher=BMJ | volume=72 | issue=5 | date=May 1, 1995 | issn=0003-9888 | doi=10.1136/adc.72.5.413 | pages=413–417 |doi-access=free | pmid=7618907 | pmc=1511089 |ref=none}}
• {{cite journal | last1=Ibrahim | first1=Mohamed | last2=Elkins | first2=Isaac | last3=Herman | first3=Michael | title=Abdominal Migraines: A Rare Adulthood Manifestation of a Typical Childhood Disease | journal=Cureus | publisher=Springer Science and Business Media LLC | date=March 21, 2023 | volume=15 | issue=3 | pages=e36451 | issn=2168-8184 | doi=10.7759/cureus.36451 |doi-access=free | pmid=37090300 |ref=none| pmc=10118217 }}

• [https://my.clevelandclinic.org/health/diseases/24449-abdominal-migraine Cleveland Clinic]
• [https://www.webmd.com/migraines-headaches/abdominal-migraines-children-adults WebMD]

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Category:Migraine

Category:Abdominal pain

Category:Gastrointestinal tract disorders

Category:Episodic and paroxysmal disorders