What is the first line treatment for a 14-year-old girl with a severe headache?

Treatment of Severe Headache in a 14-Year-Old Girl

For a 14-year-old girl with severe headache, NSAIDs (such as ibuprofen 400-800mg or naproxen 500-550mg) should be used as first-line treatment, with triptans considered if response is inadequate. 1

Initial Assessment and Treatment Algorithm

Step 1: Determine if this is likely migraine

• Characteristics suggesting migraine:
  • Moderate to severe intensity
  • Pulsating quality
  • Associated symptoms: nausea, vomiting, photophobia, phonophobia
  • Duration: 4-72 hours if untreated

Step 2: First-line treatment for severe headache

1. NSAIDs:

   • Ibuprofen 400-800mg
   • Naproxen 500-550mg
   • Administer as early as possible during the attack for best efficacy 2, 1

2. If nausea/vomiting present:

   • Add antiemetic: Domperidone is preferred over metoclopramide in adolescents as it doesn't cross the blood-brain barrier 3
   • Consider non-oral routes of administration 1

Step 3: For inadequate response to NSAIDs

• Add or switch to triptan (for adolescents >12 years old):
  • Sumatriptan, rizatriptan, zolmitriptan are options 1, 3
  • Triptans are first-line for moderate to severe migraines 4

Important Considerations

Medication Selection Rationale

The most recent guidelines strongly recommend NSAIDs as first-line treatment for mild to moderate migraine, with triptans added for moderate to severe attacks or inadequate response 1. This approach is supported by multiple sources 2, 4, 5.

Avoid Common Pitfalls

1. Avoid acetaminophen alone: Not recommended for migraine as evidence for efficacy is limited 2, 3
2. Avoid opioids and butalbital: These can lead to medication overuse headache and dependency 2, 1
3. Monitor for medication overuse: Limit acute medications to ≤10 days per month to prevent medication overuse headache 1, 6
4. Be alert for adverse effects: Particularly with metoclopramide, which can cause extrapyramidal symptoms in young patients 3

Red Flags Requiring Urgent Evaluation

• Sudden, severe "thunderclap" headache
• Headache with fever, stiff neck, confusion
• Headache after head injury
• New headache with neurological symptoms (weakness, vision changes, speech problems)
• Headache worsened with Valsalva maneuver or that awakens from sleep 2, 1

Treatment Goals

1. Rapidly and consistently treat attacks
2. Restore functional ability
3. Minimize need for rescue medications
4. Minimize adverse effects 2

For this 14-year-old girl, starting with an NSAID and adding a triptan if needed represents the most evidence-based approach to managing her severe headache while prioritizing safety and effectiveness.