What is the treatment plan for a 12-year-old female patient with intractable migraines (migraine headaches) without aura, status post motor vehicle accident (MVA), who has not responded to methylprednisolone (Medrol)?

Treatment Plan for Post-Concussive Intractable Migraines in a 12-Year-Old Female

For a 12-year-old female with post-concussive intractable migraines without aura who has failed methylprednisolone therapy, the recommended treatment plan includes topiramate for migraine prophylaxis starting at a low dose of 25 mg daily and titrating slowly to 50-100 mg daily, along with a triptan medication for acute attacks. 1, 2

Preventive Therapy with Topiramate

• Start topiramate at 25 mg daily and increase by 25 mg weekly to minimize side effects, targeting an initial goal of 50 mg twice daily (100 mg total daily dose) 1, 3
• Begin with a lower dose (25 mg daily) for the first week to improve tolerability, as approximately 25% of patients respond to lower doses (50 mg daily) with fewer side effects 3
• Monitor for common side effects including weight loss (50%), paresthesia (48%), and cognitive disturbances (20%) 4
• Allow an adequate trial period of 2-3 months before determining efficacy, as clinical benefits may take time to manifest 2
• Target dose should be 50-100 mg daily for pediatric patients, which balances efficacy with tolerability in this age group 1, 5

Acute Treatment with Triptan

• Prescribe a triptan medication for acute migraine attacks, as triptans are recommended for moderate to severe migraine attacks 6, 7
• Sumatriptan is indicated for the acute treatment of migraine with or without aura, though safety and effectiveness have not been established in patients younger than 18 years 7
• Instruct the patient to take the triptan at the onset of headache (not during aura if present) for maximum effectiveness 1, 6
• Start with the lowest effective dose to minimize side effects 6
• Caution: Triptans should not be used more than twice weekly to prevent medication overuse headache 2, 6

Prevention of Medication Overuse Headache

• Educate the patient and family about medication overuse headache, which can result from using acute medications more than twice weekly 2, 6
• Instruct the patient to limit triptan use to no more than 2 days per week 8, 2
• Maintain a headache diary to track frequency, severity, and medication use 2
• Schedule regular follow-up visits (every 4-6 weeks initially) to monitor response and adjust treatment as needed 1

Additional Considerations

• NSAIDs may be used as first-line therapy for mild to moderate attacks before using triptans 1, 6
• Consider non-pharmacological approaches such as adequate sleep, regular meals, hydration, and stress management 1
• If topiramate is ineffective or poorly tolerated after an adequate trial (2-3 months), consider alternative prophylactic options such as amitriptyline (10-100 mg at night) 1, 2
• For patients with post-concussive syndrome, a multidisciplinary approach may be beneficial, including gradual return to activities and cognitive rest as needed 2

Specific Instructions for Patient/Family

• Take topiramate daily as prescribed, starting with 25 mg at bedtime for one week, then increase by 25 mg weekly as directed
• Use the triptan medication only when a migraine occurs, at the onset of headache pain
• Do not use the triptan more than twice per week to prevent medication overuse headache
• Keep a headache diary to track frequency, severity, triggers, and medication use
• Return for follow-up in 4 weeks to assess response and adjust treatment if necessary 2

Pitfalls to Avoid

• Avoid starting with too high a dose of topiramate, which can lead to poor tolerability and discontinuation 2, 3
• Do not continue ineffective preventive therapy beyond 2-3 months without reassessment 2
• Avoid using triptans during the aura phase, as they are most effective when taken early in the headache phase 1, 9
• Be vigilant about medication overuse, which can interfere with preventive treatment efficacy 2, 10
• Do not expect immediate results from preventive therapy; clinical benefit may take 2-3 months to manifest 2