What is the best course of treatment for a 16-year-old female experiencing headaches?

Treatment of Headaches in a 16-Year-Old Female

For a 16-year-old female with headaches, start with ibuprofen for acute treatment and consider propranolol, amitriptyline, or topiramate for prevention if headaches are frequent or disabling. 1

Initial Assessment and Diagnosis

Before initiating treatment, determine whether this is a primary headache disorder (most likely migraine or tension-type headache) or a secondary headache requiring urgent evaluation 2:

• Rule out red flags including abrupt onset ("thunderclap"), neurologic signs, recent head trauma, headache brought on by Valsalva or exertion, systemic symptoms, or fever with neck stiffness 2, 3
• Obtain a detailed headache history including frequency, duration, severity, associated symptoms (nausea, photophobia, phonophobia), and any aura symptoms 1, 2
• Implement a headache diary to document attack frequency, severity, triggers, and medication use—this is essential for monitoring treatment response and detecting medication overuse 1, 4

Acute Treatment Strategy

First-line acute treatment:

• Ibuprofen 400-800 mg at headache onset is the recommended first-line treatment for adolescents with migraine 1, 5
• Bed rest alone may suffice for mild attacks in this age group 1
• Administer medication early when pain is still mild to maximize effectiveness 5

Important frequency limitation:

• Restrict acute medication use to no more than 2 days per week to prevent medication-overuse headache, which can transform episodic headaches into chronic daily headaches 5, 6

If ibuprofen fails after 2-3 trials:

• Consider adding an antiemetic like metoclopramide 10 mg if nausea is present 5
• Escalate to a triptan (such as sumatriptan or rizatriptan) for moderate-to-severe attacks, though note that triptans have more limited evidence in adolescents compared to adults 5, 2

Preventive Treatment Indications

Initiate preventive therapy if any of the following apply:

• Headaches occur more than 2 days per week 1, 6
• Headaches cause significant disability affecting school, activities, or quality of life 1, 2
• Acute medications are being used more than twice weekly 1, 6
• Acute treatments are contraindicated or ineffective 1

Preventive Treatment Options for Adolescents

First-line preventive medications specifically recommended for children and adolescents:

1. Propranolol (beta-blocker): Well-established efficacy and safety profile in adolescents 1
2. Amitriptyline (tricyclic antidepressant): 10-100 mg oral at night; particularly useful if comorbid depression or sleep disturbance exists 1
3. Topiramate (anticonvulsant): 50-100 mg oral daily; has the strongest evidence from randomized controlled trials, though note contraindications including pregnancy risk, nephrolithiasis, and glaucoma 1

Critical contraindication for females of childbearing potential:

• Sodium valproate is absolutely contraindicated in this 16-year-old female due to teratogenic risks 1

Monitoring and Follow-Up

• Evaluate treatment response within 2-3 months after initiating or changing preventive therapy 1
• Continue headache diary to track attack frequency, severity, and medication use 1, 4
• Assess for medication overuse at each visit, as this is a common pitfall that can undermine treatment effectiveness 1, 6
• Address modifiable risk factors including irregular sleep, missed meals, dehydration, stress, and specific dietary triggers 6

Common Pitfalls to Avoid

• Do not allow escalating acute medication use in response to treatment failure—this creates a vicious cycle of medication-overuse headache 5, 6
• Do not prescribe opioids or butalbital-containing compounds for adolescent headaches due to risks of dependency, rebound headaches, and lack of efficacy 5, 6
• Do not delay preventive therapy when indicated—early intervention can prevent transformation to chronic daily headache 6
• Screen for psychiatric comorbidities (depression, anxiety) that commonly coexist with migraine and can impair treatment effectiveness 6