What is the initial approach to managing chronic headaches in a 15-year-old female patient?

Initial Management of Chronic Headache in a 15-Year-Old Female

Begin by ruling out secondary causes through careful history and neurologic examination, then initiate a headache diary, identify triggers, and consider prophylactic medication if headaches occur more than twice weekly, with topiramate being the only agent proven effective in randomized controlled trials for chronic migraine. 1

Step 1: Rule Out Secondary Causes

Before diagnosing a primary headache disorder, evaluate for "red flags" that suggest dangerous secondary causes 2:

• Headache worsened by Valsalva maneuver (suggests increased intracranial pressure) 2
• Headache that awakens patient from sleep 2
• Fever or signs of infection 2
• Progressive worsening pattern 2
• Unexplained abnormal findings on neurologic examination 2
• New onset with atypical features 2

Neuroimaging is NOT warranted if the neurologic examination is normal, features are consistent with primary headache, and there is no change in a long-standing headache pattern 2. This is critical to avoid unnecessary testing in adolescents.

Step 2: Establish the Diagnosis

If no red flags are present, determine if this meets criteria for chronic migraine 1:

• 15 or more headache days per month for at least 3 months 1
• At least 8 days per month with migraine features (each lasting at least 4 hours) 1
• Migraine features include: unilateral location, pulsating quality, moderate-to-severe intensity, nausea/vomiting, photophobia, phonophobia 3

Key diagnostic tool: Ask directly, "Do you feel like you have a headache of some type on 15 or more days per month?" 1 Patients often underreport milder headache days and only mention severe episodes 1.

Initiate a headache diary immediately to accurately track frequency, severity, triggers, and treatment response 2. This is essential because patients cannot reliably report headache frequency without documentation 1.

Step 3: Identify and Address Exacerbating Factors

Screen for medication overuse headache (MOH), which is a common pitfall 2, 4, 5:

• Frequent use of acute medications (NSAIDs, triptans, combination analgesics) can paradoxically increase headache frequency 2, 6, 5
• If MOH is present, the patient must stop overused medications entirely before prophylactic treatment can be effective 5

Identify personal triggers including irregular sleep patterns, stress, dietary factors, and hormonal changes (particularly relevant in adolescent females) 2.

Step 4: Initiate Treatment Plan

Every chronic migraine treatment plan requires BOTH prophylactic therapy AND acute treatment for exacerbations 1.

Prophylactic Therapy (Primary Focus)

Prophylactic treatment should be initiated if headaches occur more than twice weekly 2. For this 15-year-old with chronic headache, prophylaxis is indicated.

Evidence-based prophylactic options include topiramate, gabapentin, tizanidine, fluoxetine, amitriptyline, and valproate 1, 2. However, topiramate is the ONLY agent proven efficacious in randomized, placebo-controlled trials specifically for chronic migraine 1. This makes it the strongest evidence-based choice for initial prophylaxis.

Important consideration for adolescents: Valproate should be avoided in females of childbearing potential due to teratogenicity. Topiramate also carries teratogenic risk but has the strongest evidence for chronic migraine.

Acute Treatment

For acute exacerbations, triptans (sumatriptan, eletriptan) or NSAIDs are appropriate 2, 7, 8:

• Sumatriptan 50-100 mg shows 61-79% headache response at 4 hours 7
• Eletriptan 40-80 mg shows 54-77% headache response at 2 hours 8

Critical caveat: Limit acute medication use to avoid medication overuse headache 2, 6, 5. Never use opioids for headache management due to dependency risk and rebound headaches 2, 3.

Non-Pharmacologic Interventions

Complement medication with 2, 5:

• Regular sleep patterns 2
• Stress management techniques 2
• Relaxation techniques and cognitive behavioral therapy 5

Step 5: Consider Specialist Referral

Refer to neurology if 2, 4:

• Uncertain diagnosis
• Poor response to preventive strategies
• Migraine with persistent aura
• Headache with motor weakness
• Cluster headache features

Common Pitfalls to Avoid

• Failing to diagnose chronic migraine: Only 20% of patients meeting criteria are properly diagnosed 1
• Not addressing medication overuse: This must be recognized and treated before prophylaxis can succeed 6, 5
• Using acute medications too frequently: This perpetuates the headache cycle 2, 6
• Ordering unnecessary neuroimaging: Not indicated with normal exam and typical primary headache features 2