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

Approach to Headache in a 15-Year-Old Female

Begin with a focused evaluation for "red flags" that indicate secondary headache requiring urgent neuroimaging or referral, then classify the headache type using International Headache Society criteria to guide treatment, starting with NSAIDs for mild-to-moderate primary headaches and escalating to triptans for moderate-to-severe migraines. 1, 2

Initial Red Flag Assessment

Immediately evaluate for warning signs that suggest secondary headache requiring urgent attention 2, 3:

• Headache worsened by Valsalva maneuver or cough 2, 3
• Headache that awakens patient from sleep 1, 2
• Rapidly increasing frequency of headaches 1
• Abrupt onset of severe headache 1, 3
• Focal neurologic signs or symptoms 1, 3
• Fever or signs of infection 2
• History of uncoordination 1
• Marked change in headache pattern 1

If any red flags are present, obtain neuroimaging (MRI preferred) and consider urgent referral. 1, 2

Diagnostic Classification

Ask specific questions to determine headache type 1, 2:

For Migraine Diagnosis (Most Common in 15-Year-Old Females)

Requires at least two of the following 1:

• Unilateral location
• Throbbing character
• Worsening with routine activity
• Moderate to severe intensity

Plus at least one of 1:

• Nausea and/or vomiting
• Photophobia and phonophobia

For Tension-Type Headache

Requires at least two of 1:

• Pressing, tightening, or nonpulsatile character
• Mild to moderate intensity
• Bilateral location
• No aggravation with routine activity

Plus both of 1:

• No nausea or vomiting
• No photophobia and phonophobia together

Neuroimaging Decision

Do NOT obtain neuroimaging if 1, 2:

• Normal neurologic examination
• Features consistent with primary headache
• No red flags present
• Long history of similar headaches without pattern change

The yield of brain MRI in pediatric primary headaches is <1% for clinically relevant findings. 1

Acute Treatment Algorithm

For Mild-to-Moderate Migraine or First-Line Treatment

Start with oral NSAIDs 1:

• Ibuprofen 400-800 mg every 6 hours (maximal initial dose 800 mg, avoid >2.4 g/day) 1
• Naproxen sodium 275-550 mg every 2-6 hours (maximal initial dose 825 mg, avoid >1.5 g/day) 1
• Combination analgesics containing caffeine (aspirin + acetaminophen + caffeine) 1

Critical caveat: Acetaminophen alone is NOT recommended for migraine. 1

For Moderate-to-Severe Migraine or Poor Response to NSAIDs

Escalate to migraine-specific drugs 1:

• Triptans: naratriptan, rizatriptan, sumatriptan, or zolmitriptan 1
• Alternative: Isometheptene combinations (Midrin) for milder migraines 1

For Migraine with Nausea/Vomiting

Use non-oral route of administration 1:

• Consider adjunctive antiemetics: metoclopramide or prochlorperazine 1
• Prochlorperazine can effectively relieve headache pain itself 1

Medications to AVOID

Do NOT use opioids (meperidine, butorphanol) or butalbital-containing analgesics for regular management 1, 2:

• Risk of dependency and rebound headaches 1
• Loss of efficacy with chronic use 1
• Reserve only for severe migraines unresponsive to other treatments 1

Preventive Therapy Consideration

Consider prophylaxis if headaches occur more than twice weekly 2:

• Evidence-based options: topiramate, gabapentin, amitriptyline, valproate 2
• Non-pharmacological measures are MORE important in adolescents: lifestyle regulation, relaxation training, psychological interventions 4

Medication Overuse Warning

Closely monitor analgesic use to prevent medication-overuse headache 1, 2:

• Overuse of acute medications can lead to rebound headaches 1
• This is a common pitfall in adolescent headache management 2, 5

Referral Indications

Refer to neurology if 2, 5:

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

Patient Education

Implement headache diary tracking 2:

• Frequency, severity, triggers, treatment response 2
• Identify and avoid personal triggers 2
• Establish regular sleep patterns 2
• Consider stress management techniques 2