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

Treatment of Migraines in a 17-Year-Old Female

For acute treatment of migraines in a 17-year-old female, NSAIDs (such as ibuprofen or naproxen) or acetaminophen should be used as first-line therapy, with triptans reserved for moderate to severe attacks that do not respond to first-line treatments. 1

Acute Treatment Algorithm

First-Line Options:

• NSAIDs (ibuprofen 400-600 mg or naproxen sodium 500-550 mg) are recommended as first-line therapy for mild to moderate migraine attacks 1
• Acetaminophen (1000 mg) can be used as an alternative, though evidence for its effectiveness alone is limited 1, 2
• Combination therapy of an NSAID plus acetaminophen may provide better relief than either medication alone 1

Second-Line Options (for moderate to severe attacks or when first-line fails):

• Triptans (sumatriptan, rizatriptan, zolmitriptan) should be considered for moderate to severe attacks that don't respond to NSAIDs 1
• Begin treatment as early as possible after migraine onset for best efficacy 1
• Consider combination therapy (triptan plus NSAID) for improved efficacy in more severe attacks 1

For Nausea/Vomiting:

• Antiemetics (such as metoclopramide) should be added when nausea or vomiting is a significant component 1
• Consider non-oral routes of administration (nasal sprays, injections) if vomiting prevents oral medication use 1

Preventive Treatment Considerations

Consider preventive therapy if the patient experiences:

• Two or more attacks per month with significant disability 1, 3
• Inadequate response to acute treatments 1
• Use of acute medications more than twice per week 1

First-Line Preventive Options:

• Propranolol (80-160 mg daily) is considered first-line preventive therapy with good evidence in adolescents 1
• Amitriptyline (10-100 mg at night) can be used if propranolol is contraindicated 1, 2
• Topiramate (50-100 mg daily) is another effective option for adolescents 1

Important Considerations for Adolescents

• Safety in pediatric population: Limited data exists for many migraine medications in patients under 18 years 4
• Medication overuse: Counsel about medication overuse headache risk (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 1, 2
• Lifestyle modifications: Emphasize importance of regular sleep, meals, hydration, physical activity, and stress management 1
• Avoid contraindicated medications: Opioids and butalbital-containing medications should not be used for migraine treatment in adolescents 1, 2, 5

Special Considerations for Females

• Menstrual migraines: If migraines are linked to menstruation, consider perimenstrual preventive treatment with long-acting NSAIDs or triptans for 5 days starting 2 days before expected menstruation 1
• Pregnancy planning: Discuss medication safety if pregnancy is a consideration, as many migraine medications have pregnancy contraindications 2, 4
• Contraceptives: Combined hormonal contraceptives may affect migraine patterns and are contraindicated in migraine with aura due to increased stroke risk 1, 2

Treatment Monitoring

• Use headache diaries to track attack frequency, severity, medication use, and response to treatment 1
• Evaluate treatment response within 2-3 months after initiation or change in treatment 1
• Regularly reassess the need for preventive medication 1