What are the treatment options for migraines in teenagers?

Treatment Options for Migraines in Teenagers

For teenagers with migraines, first-line acute treatment should include ibuprofen, while adolescents with moderate to severe migraines should consider triptans such as sumatriptan/naproxen oral, zolmitriptan nasal, sumatriptan nasal, rizatriptan ODT, or almotriptan oral. 1

Acute Treatment Algorithm

First-Line Options

• Ibuprofen (7.5-10 mg/kg): Most effective NSAID for pain relief in children and adolescents 1, 2
• Acetaminophen (15 mg/kg): Safe but less evidence for efficacy compared to ibuprofen 1, 2

Second-Line Options (for adolescents with moderate-severe migraines)

• Sumatriptan nasal spray: FDA-approved for adolescents in Europe 1, 2
• Zolmitriptan nasal spray: FDA-approved for adolescents in Europe 1
• Rizatriptan ODT: FDA-approved for patients aged 6-17 years in the USA 2
• Almotriptan: FDA-approved for adolescents in the USA 2
• Sumatriptan/naproxen combination: Effective for adolescents 2, 3

Treatment Strategies

• Treat acute migraine early in the attack 1
• If one triptan is ineffective, try another or a non-steroidal anti-inflammatory drug-triptan combination 1
• For rapidly escalating headache pain, use a non-oral triptan formulation 1
• For migraines with prominent nausea/vomiting, use non-oral triptan or add an anti-emetic 1

Preventive Treatment

Consider preventive treatments in teenagers with:

• Frequent headaches (≥2 times per month) 4
• Disabling headaches 1
• Medication overuse 1
• Reduced quality of life between attacks 4

Preventive Medication Options

• Amitriptyline + cognitive behavioral therapy: Evidence supports this combination 1
• Topiramate: Effective but has teratogenic potential (important for female adolescents) 1, 4
• Propranolol: Evidence supports efficacy 1, 4

Non-Pharmacological Preventive Approaches

• Regular sleep schedule
• Consistent meal times
• Adequate hydration
• Regular physical activity
• Stress management techniques
• Identification and avoidance of personal triggers 4
• Cognitive behavioral therapy and relaxation techniques 4, 5

Important Considerations and Cautions

Medication Overuse

• Limit NSAIDs to ≤15 days/month 4
• Limit triptans to ≤10 days/month 4

Safety Considerations

• Triptans: Not recommended for patients younger than 18 years according to FDA labeling, though clinical guidelines support their use in adolescents 6
• Sumatriptan: Safety and effectiveness in pediatric patients have not been established by FDA standards, though clinical guidelines recommend use in adolescents 6
• Valproate derivatives: Avoid in female adolescents due to teratogenic potential 1, 4
• Topiramate: Discuss teratogenic effects with female adolescents and advise on effective birth control methods and folate supplementation 1

Efficacy Considerations

• Placebo was as effective as many studied medications in clinical trials, which should be discussed with patients and families 1
• Triptans as a class show moderate quality evidence for efficacy in adolescents (NNT=6) 3
• Sumatriptan plus naproxen sodium shows moderate quality evidence for efficacy in adolescents (NNT=6) 3

Monitoring and Follow-up

• Use a headache diary to track frequency, duration, intensity, triggers, and medication response 4
• Target 50% reduction in attack frequency for preventive therapy 4
• Allow 6-8 weeks at therapeutic dose to assess effectiveness of preventive medications 4

By following this evidence-based approach to migraine management in teenagers, clinicians can help reduce the significant impact of migraines on quality of life and school performance in this vulnerable population.