What are the treatment options for migraines in a 14-year-old?

Migraine Treatment Options for 14-Year-Olds

For 14-year-old patients with migraine, ibuprofen (7.5-10 mg/kg) should be used as first-line treatment for acute attacks, with triptans (particularly sumatriptan nasal spray) as second-line therapy when NSAIDs fail to provide relief. 1

Acute Treatment Algorithm

First-Line Treatment

• Ibuprofen (7.5-10 mg/kg) - Preferred first-line option due to stronger evidence of efficacy 1
• Acetaminophen (15 mg/kg) - Alternative if ibuprofen is contraindicated 1
• Administer at the onset of migraine attack for maximum effectiveness

Second-Line Treatment (if first-line fails after 3 consecutive attacks)

• Sumatriptan nasal spray - FDA-approved for adolescents 1, 2
  • 5 mg or 20 mg formulations are appropriate for adolescents
  • Particularly useful for rapidly escalating headaches or when oral medications aren't tolerated

For Migraine with Nausea/Vomiting

• Add an anti-emetic medication
• Use non-oral route of administration (nasal spray) 3

Important Cautions

• Triptans are contraindicated in hemiplegic migraine due to theoretical concerns about vasoconstriction 1
• Avoid opioid analgesics as they can lead to dependency, rebound headaches, and eventual loss of efficacy 3
• Limit and carefully monitor the use of butalbital-containing analgesics 3

Preventive Treatment

Consider preventive therapy when migraines:

• Occur ≥2 times per month
• Cause significant disability
• Inadequately respond to acute treatments 1

First-Line Preventive Options

• Propranolol (1-4 mg/kg/day divided twice daily) 1
• Topiramate (50-100 mg daily) 1
• Amitriptyline (10-100 mg at night) 1

Second-Line Preventive Options

• Flunarizine (5-10 mg daily) - Not available in many countries 1, 4

Supplement Option

• Oral magnesium - Only supplement with sufficient evidence for migraine prevention in children 1

Non-Pharmacological Approaches

Lifestyle Modifications

• Maintain regular sleep schedule
• Ensure regular meal times (avoid fasting)
• Stay adequately hydrated
• Identify and avoid personal migraine triggers 1, 5, 6
• Stress management techniques appropriate for adolescents 1

Other Non-Pharmacological Options

• Biobehavioural therapy 3
• Relaxation techniques 7
• Cognitive behavioral treatment 7

Monitoring and Follow-up

• Maintain a headache diary to track frequency, triggers, and treatment response 1
• Evaluate response to preventive medications after 6-8 weeks 1
• Monitor for medication side effects:
  • Topiramate: cognitive effects, weight loss
  • Amitriptyline: sedation, weight gain 1

Important Clinical Pearls

• Complete elimination of headaches is unlikely; the goal is reducing frequency, severity, and disability 1
• Avoid overuse of acute medications (even over-the-counter ones) as this can lead to medication overuse headache
• The Childhood and Adolescent Migraine Prevention trial demonstrated that approximately 60% of children and adolescents with migraine improve with lifestyle management, optimally dosed acute therapy, and appropriate preventive treatment 2