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

Treatment Options for 17-Year-Old with Migraine Headaches

For a 17-year-old with migraine headaches, NSAIDs should be used as first-line abortive treatment, with triptans as second-line therapy, while avoiding opioids and butalbital-containing medications. 1, 2

Acute Treatment Options

First-Line Treatments

• NSAIDs:

  • Ibuprofen: 400-800 mg every 6 hours (maximum 2.4g daily)
  • Naproxen sodium: 275-550 mg every 2-6 hours (maximum 1.5g daily)
  • Aspirin: 650-1000 mg every 4-6 hours (maximum 4g daily) 2

• Combination medications:

  • Aspirin-acetaminophen-caffeine combination (e.g., Excedrin Migraine) is strongly recommended due to its effectiveness in achieving pain freedom and pain relief at 2 hours 2

Second-Line Treatments

• Triptans (for moderate to severe attacks or inadequate response to NSAIDs):

  • Rizatriptan: 10mg orally as a single dose for adolescents weighing ≥40kg
  • Sumatriptan: 50 mg orally (Note: FDA labeling states safety and effectiveness in pediatric patients have not been established, but clinical practice guidelines support use in adolescents) 2, 3

• Antiemetics (for accompanying nausea):

  • Metoclopramide (Reglan)
  • Prochlorperazine (Compazine) 2

Important Administration Guidelines

• Begin treatment as soon as possible after migraine onset
• Consider combination therapy (triptan with NSAID or acetaminophen) for improved efficacy 1
• For severe nausea/vomiting, consider non-oral routes of administration 1, 2

Preventive Treatment Options

Consider preventive treatment if:

• Migraine attacks occur ≥2 times per month with disability lasting ≥3 days
• Acute treatments are ineffective, contraindicated, or overused 2

First-Line Preventive Medications

• Beta-blockers:

  • Propranolol: 80-240 mg per day
  • Timolol: 20-30 mg per day
  • Metoprolol 2

• Anticonvulsants:

  • Topiramate: 25-100 mg/day
  • Divalproex sodium: 500-1000 mg/day 2

• Antidepressants:

  • Amitriptyline: 30-150 mg per day 2

Complementary Treatments

• Magnesium supplementation
• Riboflavin supplementation 2

Non-Pharmacological Approaches

• Maintain regular sleep schedule
• Eat regular meals
• Engage in moderate aerobic exercise
• Manage stress with relaxation techniques or mindfulness practices
• Track headache patterns using a diary to identify triggers 2

Important Precautions and Limitations

Medication Overuse Prevention

• Limit NSAIDs to no more than 15 days per month
• Limit triptans to no more than 9 days per month
• Limit OTC medications to no more than 14 days per month 1, 2

Contraindications and Special Considerations

• Triptans: Contraindicated in patients with cardiovascular conditions, Wolff-Parkinson-White syndrome, history of stroke/TIA, peripheral vascular disease, uncontrolled hypertension 2
• Pregnancy considerations: Although not directly applicable to a 17-year-old, be aware that sumatriptan has a pregnancy category C rating and should be used during pregnancy only if potential benefit justifies potential risk 3
• Avoid opioids and butalbital-containing medications for migraine treatment due to questionable efficacy and risk of dependence 1, 2

Follow-up Recommendations

• Schedule follow-up in 4-6 weeks to assess treatment effectiveness
• Use headache diary to track frequency, severity, and medication use
• Consider referral to a neurologist or headache specialist if no improvement after trials of 2-3 preventive medications 2

Pitfalls to Avoid

• Delaying treatment after migraine onset reduces medication effectiveness
• Using acute medications too frequently can lead to medication overuse headache
• Failing to address lifestyle factors and triggers can reduce treatment effectiveness
• Using opioids or butalbital-containing medications should be avoided 1, 2