What is the treatment for migraines in a 17-year-old?

Treatment of Migraine in a 17-Year-Old

For a 17-year-old with migraine, the recommended first-line treatment is a combination of a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen with a triptan if the NSAID alone is inadequate. 1, 2

Acute Treatment Options

First-Line Treatments:

• NSAIDs:
  • Ibuprofen 400-800 mg is effective as first-line treatment for mild to moderate migraine attacks 2, 3
  • Naproxen sodium 500-550 mg is an alternative NSAID option 2
  • Should be limited to 2-3 days/week to prevent medication overuse headache 2

Second-Line or Add-On Treatments:

• Triptans:

  • Add a triptan if NSAIDs don't provide adequate relief 1
  • Most effective when taken early in an attack while headache is still mild 2
  • Sumatriptan nasal spray (5 and 20 mg) has evidence for effectiveness in adolescents 4
  • Contraindicated in patients with history of stroke 2

• Acetaminophen:

  • Acetaminophen 1000 mg can be used as an alternative to NSAIDs if contraindicated 2
  • Adding a triptan to acetaminophen is suggested for those who don't respond adequately to acetaminophen alone 1

Important Considerations for Adolescents

1. Avoid Opioids and Butalbital: These medications are not recommended due to risk of medication overuse headache and dependence 2, 5

2. Dosing Considerations:

   • Ibuprofen: 7.5-10.0 mg/kg
   • Acetaminophen: 15 mg/kg 4

3. Non-Pharmacological Approaches:

   • Identification and avoidance of trigger factors
   • Regulation of lifestyle
   • Relaxation techniques
   • Biofeedback
   • Cognitive behavioral therapy 4

Preventive Treatment

Consider preventive therapy if the adolescent experiences:

• 4 or more headaches per month
• 8 or more headache days per month
• Debilitating headaches
• Medication-overuse headaches 6

First-Line Preventive Options:

• Topiramate (100 mg/day, titrated slowly)
• Propranolol (80-240 mg/day)
• Amitriptyline (30-150 mg/day) 2, 6

Supplements with Evidence:

• Magnesium (400-600 mg daily)
• Riboflavin (vitamin B2)
• Coenzyme Q10 2

Treatment Algorithm

1. For mild to moderate attacks:

   • Start with ibuprofen 7.5-10 mg/kg
   • If inadequate response, add a triptan (sumatriptan nasal spray is appropriate for adolescents)

2. For moderate to severe attacks:

   • Start with combination of NSAID + triptan
   • Consider antiemetics if nausea/vomiting are prominent

3. If frequent or disabling migraines:

   • Initiate preventive therapy
   • Consider non-pharmacological approaches
   • Track frequency, severity, and medication use with a headache diary

Pitfalls to Avoid

1. Medication Overuse: Limit use of acute medications to 2-3 days per week to prevent medication overuse headache 2

2. Inadequate Dosing: Ensure appropriate weight-based dosing for adolescents 4

3. Delayed Treatment: Educate the patient about taking medication early in the attack for better efficacy 2

4. Overlooking Triggers: Identifying and managing environmental, dietary, and behavioral triggers are important strategies 6

5. Ignoring Non-Pharmacological Approaches: These can be particularly effective in adolescents and should be incorporated into the treatment plan 4