What are the treatment options for a 17-year-old with migraines?

Treatment Options for a 17-Year-Old with Migraines

For adolescents with migraines, ibuprofen is the first-line treatment for acute attacks, with nasal spray formulations of triptans (sumatriptan or zolmitriptan) recommended for moderate to severe attacks that don't respond to NSAIDs. 1

Acute Treatment Options

First-Line Treatments

• Ibuprofen: Recommended as first-line medication for pain in adolescents 1
  • Dosage: Appropriate for body weight 1
  • Efficacy: Well-established for children and adolescents 2

Second-Line Treatments (for moderate-severe attacks or when NSAIDs fail)

• Triptans: Several options are available for adolescents:
  • Sumatriptan nasal spray: Most effective formulation for adolescents 2
  • Zolmitriptan nasal spray: Effective in adolescents 1
  • Rizatriptan ODT (orally disintegrating tablet) 1
  • Almotriptan oral 1
  • Sumatriptan/naproxen combination 1

For Attacks with Nausea/Vomiting

• Use non-oral route of administration (nasal sprays) 1
• Add antiemetic if needed 1
• Domperidone: Can be used for nausea in adolescents aged 12-17 years 1

Treatment Strategy Algorithm

1. For mild attacks: Start with ibuprofen at weight-appropriate dose
2. If inadequate relief after 3 consecutive attacks: Switch to a triptan
3. If one triptan is ineffective: Try another triptan or NSAID-triptan combination 1
4. For rapidly escalating pain: Use non-oral triptan formulation (nasal spray) 1

Preventive Treatment

Consider preventive treatment if the adolescent has:

• Frequent headaches (≥2 days/month) despite optimized acute treatment 1
• Disabling headaches 1
• Medication overuse 1

Preventive Medication Options

1. First-line options:

   • Propranolol: Used in practice for adolescents 1, 2
   • Topiramate: May be effective based on pilot studies 2
   • Amitriptyline combined with cognitive behavioral therapy: Evidence supports this combination 1

2. Other options (less evidence in adolescents):

   • Amitriptyline alone: Used in practice despite limited evidence 2
   • Flunarizine: Effective in systematic studies but not available in many countries 2

Non-Pharmacological Approaches

• Lifestyle modifications: Regular meals, sufficient sleep 2
• Trigger avoidance: Identify and avoid personal triggers (e.g., flickering lights, strong smells, noise) 2
• Bed rest: May suffice for short-duration attacks in younger patients 1
• Cognitive behavioral therapy: Especially effective when combined with amitriptyline 1

Important Considerations and Cautions

• High placebo response: Clinical trials in adolescents show high placebo response rates, which may affect apparent efficacy of medications 1
• Medication overuse: Monitor for and avoid overuse of acute medications to prevent rebound headaches 1
• Teratogenic medications: For female adolescents, discuss potential teratogenic effects of topiramate and valproate, and advise on effective birth control methods if prescribed 1
• Opioids: Avoid opioid analgesics in adolescents with migraines as they can lead to dependency, rebound headaches, and loss of efficacy 1

Education and Support

• Involve family members and teachers in management 1
• Educate on lifestyle factors and migraine triggers 1
• Counsel patients to treat acute migraine early in the attack 1

By following this structured approach to migraine treatment in adolescents, focusing on appropriate acute medications and considering preventive therapy when indicated, most 17-year-olds with migraines can achieve significant improvement in their symptoms and quality of life.