What is the appropriate treatment for migraines in an 11-year-old?

Treatment for Migraine in an 11-Year-Old

For an 11-year-old with migraine, start with ibuprofen 7.5-10 mg/kg or acetaminophen 15 mg/kg as first-line acute treatment, and consider rizatriptan (FDA-approved for ages 6+) for moderate to severe attacks that don't respond to NSAIDs. 1, 2

Acute Treatment Approach

First-Line Medications

• Ibuprofen (7.5-10 mg/kg) or acetaminophen (15 mg/kg) are the safest and most effective initial options for mild to moderate migraine in this age group 1, 3
• Administer medication as early as possible during the attack to maximize efficacy 4
• Acetaminophen alone is less effective than ibuprofen or combination therapy 4

Second-Line: Triptan Therapy

• Rizatriptan is FDA-approved for children age 6 and older, making it the preferred triptan for this patient 2
• Sumatriptan nasal spray (5-20 mg) has evidence for adolescents but should be reserved for moderate to severe attacks unresponsive to NSAIDs 1, 2
• Triptans should not be used if the child has uncontrolled hypertension, basilar or hemiplegic migraine, or risk factors for heart disease 4

Managing Nausea

• If nausea or vomiting is prominent, use a nonoral route of administration and add an antiemetic 4
• Metoclopramide is safe and effective for migraine-associated nausea 5

Critical Medication Overuse Warning

Limit acute medication use to no more than 2 days per week to prevent medication-overuse headache 4:

• NSAIDs: ≥15 days/month triggers medication-overuse headache 4, 5
• Triptans: ≥10 days/month triggers medication-overuse headache 4, 5

Never use opioids or butalbital-containing medications in pediatric migraine due to risks of dependency, rebound headaches, and lack of efficacy 4, 5

When to Consider Preventive Therapy

Evaluate for preventive treatment if the child has 4:

• Two or more migraine attacks per month causing disability for 3+ days
• Rescue medication use more than twice weekly
• Failure of or contraindications to acute treatments
• Uncommon migraine variants (prolonged aura, hemiplegic migraine)

Preventive Medication Options

If preventive therapy is warranted, evidence-based first-line options include 4:

• Propranolol (best safety data in children)
• Amitriptyline (if propranolol contraindicated)

Avoid topiramate, valproate, and candesartan due to potential adverse effects on growth, development, and cognition in children 5, 6

Essential Lifestyle Management (The Three-Pronged Approach)

Approximately 60% of children improve with comprehensive lifestyle counseling combined with optimized acute therapy 2:

Sleep and Hydration

• Maintain consistent sleep schedule with adequate hours 4, 5, 2
• Ensure proper hydration throughout the day 4, 5, 2

Diet and Exercise

• Avoid meal skipping (critical trigger in children) 2
• Limit caffeine intake 2
• Encourage regular moderate-to-intense aerobic exercise 4, 2

Trigger Identification

• Use a headache diary to identify specific triggers (foods, environmental factors, stress, weather changes) 4
• Common pediatric triggers include tyramine-containing foods, nitrates, perfumes, flickering lights, and stress 4

Behavioral Interventions

Non-pharmacological approaches can be highly effective in children 1:

• Relaxation techniques and biofeedback 1, 2
• Cognitive behavioral therapy 1
• Stress management strategies 4, 7

Red Flags Requiring Urgent Evaluation

Obtain neuroimaging if the child has 4:

• Headache worsened by Valsalva maneuver
• Headache that awakens from sleep
• Progressive worsening pattern
• Abnormal neurologic examination findings

Practical Implementation Strategy

1. Start with ibuprofen 7.5-10 mg/kg at headache onset 1
2. If inadequate response after 2-3 attacks, add or switch to rizatriptan 2
3. Implement all lifestyle modifications simultaneously (sleep, hydration, meal regularity, exercise) 2
4. Monitor frequency with headache diary for 8-12 weeks 4
5. If ≥2 attacks/month with significant disability, initiate preventive therapy with propranolol 4

This algorithmic approach prioritizes safety while maximizing efficacy for pediatric migraine management, with clear escalation pathways based on treatment response.