What is the appropriate management for daily headaches in a teenager?

Management of Daily Headaches in a Teenager

Begin with a thorough clinical assessment focusing on headache frequency, duration, associated symptoms, medication use patterns, and red flag features, then implement a combined approach of acute symptom management, preventive therapy if indicated, and non-pharmacological interventions while avoiding medication overuse.

Initial Clinical Assessment

The evaluation must establish whether this represents a primary headache disorder (migraine or tension-type) or requires investigation for secondary causes 1, 2. Key elements to assess include:

• Headache characteristics: Document pain location, quality (throbbing vs. pressure), severity, and duration of individual episodes 1
• Frequency pattern: Determine if headaches occur ≥15 days per month for >3 months, which defines chronic daily headache 3, 4
• Associated symptoms: Ask specifically about nausea, photophobia, phonophobia, aura symptoms, or autonomic features 1, 2
• Medication use: Critically important—document all acute medications and frequency of use, as medication overuse occurs with ≥15 days/month of NSAID use 3, 5
• Family history: Positive family history of migraine supports primary headache diagnosis 6
• Comorbidities: Screen for sleep disturbances, anxiety, depression, and other pain conditions, as 71% of adolescents with chronic headaches have psychiatric comorbidities 7

Red Flags Requiring Neuroimaging

Neuroimaging is NOT routinely indicated for primary headaches in children with normal neurologic examination 1, 2. However, obtain MRI (preferred) or CT if any of these features are present:

• Sudden onset "thunderclap" headache 5
• Rapidly increasing headache frequency or severity 3, 5
• Headache awakening patient from sleep 3
• Focal neurologic signs on examination 3
• Abnormal neurologic examination 2
• Fever with headache 5
• Headache worse with Valsalva maneuver 5

The yield of neuroimaging in pediatric primary headaches is extremely low—in one study of 449 children, <1% had relevant findings explaining headaches 1.

Classification and Diagnosis

Most adolescents with daily headaches have either:

• Chronic migraine: ≥15 headache days/month for >3 months, with ≥8 days meeting migraine criteria, plus history of at least 5 prior full migraine attacks 3
• Chronic tension-type headache: Bilateral pressure-quality pain without migraine features 8, 9
• Transformed migraine: Evolution from episodic migraine to daily pattern 8, 9
• New daily persistent headache: Abrupt onset of daily headache with no prior history 9

Approximately 55% of pediatric headache patients have migraine, 30% have tension-type headaches, and 10% have secondary causes 1.

Acute Treatment Strategy

Limit acute medication use to ≤2 days per week to prevent medication-overuse headache 3, 5. This is critical—medication overuse creates a vicious cycle leading to daily headaches 5.

For breakthrough attacks:

• Mild-to-moderate attacks: NSAIDs (naproxen sodium 500-825 mg at onset, can repeat every 2-6 hours, maximum 1.5 g/day) with antiemetics as needed 6, 3, 5
• Moderate-to-severe attacks: Triptans are first-line for established migraine 3
• Alternative: Combination aspirin + acetaminophen + caffeine for moderate-to-severe attacks 5

If the patient is already overusing acute medications, they must stop these medications entirely before preventive therapy can be effective 4.

Preventive Therapy Indications

Preventive therapy is indicated when headaches adversely affect the patient on ≥2 days per month despite optimized acute treatment, or when continuous headache of prolonged duration is present 6, 5.

First-Line Preventive Options:

• Propranolol: 80-160 mg daily (long-acting formulation) 5
• Topiramate: Effective for migraine prevention 3, 4
• Candesartan: Evidence-based option for migraine prophylaxis 6, 3

Second-Line Options:

• Amitriptyline: Particularly useful when comorbid sleep disturbances or depression are present 6, 4
• Gabapentin: Alternative preventive option 4
• Valproate or tizanidine: Additional alternatives 4

Assess efficacy after 2-3 months at therapeutic dose 3. Benefits may take several weeks to become apparent, so encourage adherence 6. If treatment fails, review adherence and dosing before concluding true failure; simplified once-daily dosing improves adherence 3.

Non-Pharmacological Interventions

These are essential components, not optional add-ons:

• Lifestyle modifications: Regular meals, consistent sleep patterns (critical in adolescents), adequate hydration, stress management 6
• Headache diary: Essential for monitoring treatment response and identifying triggers 6, 3, 5
• Cognitive behavioral therapy (CBT): Evidence-based for migraine management 6, 4
• Relaxation techniques and biofeedback: Proven efficacy 6, 3, 4
• Regular exercise: 40 minutes three times weekly is as effective as relaxation therapy or topiramate for prevention 6
• Acupuncture: Has supporting evidence as adjunct 3, 4

Critical Pitfalls to Avoid

Medication overuse headache is the most common reason for treatment failure 3, 5, 4. This occurs with frequent use of acute medications (≥15 days/month for NSAIDs) and creates a cycle of increasing headache frequency 5.

Polypharmacy is common and often ineffective—one recent study found adolescents had tried an average of 4.5 different medications (range 1-10) without success 7. Rather than adding more medications, consider whether this represents a more complex chronic pain syndrome requiring holistic pain management 7.

Psychiatric comorbidities are frequently missed—71% of adolescents with chronic headaches have depression, anxiety, or PTSD, and 16% have history of self-harm 7. Screen systematically for these conditions, as they require concurrent treatment 8, 7.

School reintegration is essential—successful outcomes require normalizing expectations and returning to full school participation 8.

Monitoring and Follow-Up

Schedule follow-up within 2-3 months to assess 3, 5:

• Attack frequency and severity
• Migraine-related disability using standardized tools (HIT-6) 3
• Adverse effects from medications
• Adherence to treatment plan
• Symptomatic days and acute medication use via headache calendar 5

Consider discontinuing preventive medication after 3-6 months of stability to determine if prophylaxis is still needed 6.

When to Refer

Consider pain specialist referral (not just neurology) if 7:

• Multiple medication trials have failed
• Significant psychiatric comorbidities are present
• Headaches may represent more complex chronic pain syndromes (fibromyalgia, amplified musculoskeletal pain syndrome)
• Catastrophizing or severe functional disability is present

The evidence shows that 47% of patients improve with comprehensive pain management approaches, compared to conventional pharmacological management alone 7.