What are the management options for a 13-year-old with migraines?

Management of Migraines in a 13-Year-Old

For a 13-year-old with migraines, ibuprofen (10 mg/kg) should be used as the first-line medication for acute treatment, with lifestyle modifications and consideration of preventive therapy for frequent or disabling headaches. 1, 2

Acute Treatment Options

First-Line Treatments

• Ibuprofen (10 mg/kg) is the recommended first-line medication for treating migraine pain in children and adolescents 1, 2
• Acetaminophen (15 mg/kg) is an alternative first-line option 3
• Treatment should be administered early in the migraine attack for maximum effectiveness 1, 2
• For mild attacks, bed rest alone might be sufficient in some cases 1

Second-Line Treatments for Adolescents

• For adolescents who don't respond to NSAIDs, consider: 1, 2
  • Sumatriptan/naproxen oral combination
  • Zolmitriptan nasal spray
  • Sumatriptan nasal spray
  • Rizatriptan orally disintegrating tablets (ODT)
  • Almotriptan oral

For Special Situations

• For rapidly escalating headache pain, consider non-oral triptan formulations (nasal sprays) 1, 2
• For attacks with significant nausea/vomiting, use non-oral triptan formulations or add an anti-emetic 1, 2
• If one triptan is ineffective, try another triptan or an NSAID-triptan combination 1, 2

Preventive Treatment

When to Consider Prevention

• Consider preventive treatments when: 1, 2
  • Migraines occur frequently (≥2 days per month with adverse effects despite optimized acute treatment) 1
  • Headaches are disabling
  • There is medication overuse
  • Quality of life is significantly affected

Preventive Medication Options

• Discuss with patients/families that placebo was as effective as many studied medications in trials 1
• Evidence-based options to consider include: 1
  • Amitriptyline combined with cognitive behavioral therapy
  • Topiramate
  • Propranolol
  • Beta-blockers (atenolol, bisoprolol, metoprolol)
  • Candesartan (as first-line in adults, may be considered)

Lifestyle Modifications and Non-Pharmacological Approaches

• Educate patients and families about: 1, 4

  • Migraine triggers and avoidance strategies
  • Regular sleep schedules
  • Regular meal times
  • Adequate hydration
  • Stress management techniques
  • Regular physical activity

• Consider non-pharmacological approaches: 1, 4

  • Biobehavioral therapy
  • Relaxation techniques
  • Cognitive behavioral therapy
  • Neuromodulatory devices (in select cases)

Special Considerations

• The clinical features of migraine in children/adolescents differ from adults: 1

  • Attacks are often shorter (2-72 hours)
  • Headache is more often bilateral
  • Headache is less often pulsating
  • Gastrointestinal disturbances are commonly prominent

• Management requires active help from family members and teachers 1

  • Education of both is necessary
  • Parents may provide more reliable descriptions of symptoms and lifestyle factors

• Avoid medication overuse, which can occur with frequent use of acute medications: 1, 5

  • ≥15 days/month with NSAIDs
  • ≥10 days/month with triptans

• Consider comorbidities (anxiety, depression, sleep disturbances) when selecting treatments 1

• Refer to specialist care if: 1

  • Acute medication provides insufficient pain relief
  • Diagnosis is uncertain
  • Symptoms are atypical or concerning for secondary headache