Treatment Guidelines for a 14-Year-Old with New Onset Migraines
For a 14-year-old with new onset migraines, first-line acute treatment should be ibuprofen (7.5-10 mg/kg) or acetaminophen (15 mg/kg), with lifestyle modifications as foundational management. 1, 2
Acute Treatment Algorithm
First-Line Options:
NSAIDs:
- Ibuprofen 7.5-10 mg/kg per dose 2
- Naproxen sodium (appropriate weight-based dosing)
Acetaminophen: 15 mg/kg per dose 2
Second-Line Options (for moderate to severe attacks or inadequate response):
- Sumatriptan nasal spray (for adolescents):
For Nausea/Vomiting:
- Consider adding an antiemetic when nausea is prominent 4
Preventive Treatment Considerations
Consider preventive therapy if:
- Migraines occur ≥2 times per month
- Attacks are prolonged and disabling
- Poor response to acute treatments
- Quality of life is reduced between attacks 1
First-Line Preventive Options:
- Propranolol: Weight-based dosing 2
- Flunarizine: 5 mg/day (if available in your country) 2
- Topiramate: Consider for adolescents, weight-based dosing 1
Second-Line Preventive Options:
- Amitriptyline: Starting at low doses, may require 30-100mg for effectiveness 1
Important Management Principles
Lifestyle Modifications (Essential Component):
- Regular sleep schedule
- Consistent meal times (avoid skipping meals)
- Adequate hydration
- Regular physical activity
- Stress management techniques
- Identification and avoidance of personal triggers 1
Medication Administration Guidelines:
- Begin treatment as soon as possible after migraine onset 4
- Limit acute medication use to prevent medication overuse headache:
- NSAIDs: ≤15 days/month
- Triptans: ≤10 days/month 1
Treatment Goals:
- Target 50% reduction in attack frequency for preventive therapy
- Allow 6-8 weeks at therapeutic dose to assess effectiveness 1
Cautions and Contraindications
- Avoid opioids and butalbital for acute migraine treatment 4
- Avoid valproate derivatives in female adolescents due to teratogenic potential 1
- Be cautious with triptan use in patients with cardiovascular risk factors 5
Monitoring and Follow-up
Use a headache diary to track:
- Frequency and severity of attacks
- Medication use and effectiveness
- Potential triggers
- Response to interventions 1
Evaluate for adequate response after 6-8 weeks of preventive therapy 1
Consider alternative preventive medication if inadequate response after appropriate trial
Non-Pharmacological Approaches
- Cognitive behavioral therapy for stress management 1
- Relaxation techniques 2
- Biofeedback may be beneficial, especially in pediatric populations 2
The evidence for pediatric migraine treatment is more limited than for adults, with fewer high-quality studies specifically in children and adolescents. Despite FDA approval of some medications like rizatriptan and topiramate for pediatric use, their recommendations in guidelines may be lukewarm due to study design limitations 4. This highlights the importance of combining pharmacological approaches with lifestyle modifications and non-pharmacological interventions for optimal management.