What is the best course of treatment for a 16-year-old patient with daily headaches?

Treatment of Daily Headaches in a 16-Year-Old

For a 16-year-old with daily headaches, start with ibuprofen for acute treatment and consider propranolol, amitriptyline, or topiramate for prevention if headaches occur more than twice weekly. 1

Initial Assessment Priorities

Before initiating treatment, determine if this represents chronic migraine (≥15 headache days per month for ≥3 months) versus episodic headache, as this fundamentally changes management. 2

Critical red flags requiring neuroimaging include:

• New or progressively worsening headache pattern 3
• Headache awakening patient from sleep or occurring exclusively in morning with severe vomiting 4
• Neurological symptoms or abnormal neurological examination 1, 5
• Headache worsened by Valsalva maneuver 3
• Occipital location in children 4

If red flags are absent and neurological examination is normal, neuroimaging is not warranted. 1, 5

Acute Treatment Strategy

Ibuprofen is the first-line acute treatment for adolescents with migraine. 1 Administer as early as possible during an attack to improve efficacy. 1

• Acetaminophen alone is ineffective and should not be used. 1
• Naproxen sodium is also effective for acute treatment. 1
• Bed rest alone may suffice in some adolescents. 1

Critical pitfall: Limit acute medication use to fewer than 10 days per month to prevent medication-overuse headache. 6 Frequent use of analgesics or triptans can paradoxically increase headache frequency, creating a pattern of daily headaches. 1

Preventive Treatment Indications

Initiate preventive therapy if the patient has more than two headaches per week. 1

First-Line Preventive Options for Adolescents

The three evidence-based preventive medications specifically recommended for children and adolescents are: 1

1. Propranolol - First-line option with good evidence
2. Amitriptyline - 10-100 mg oral at night 1
   • Contraindicated if age <6 years, heart failure, or concurrent use with monoamine oxidase inhibitors/SSRIs 1
3. Topiramate - 50-100 mg oral daily 1
   • Contraindicated in pregnancy, lactation, glaucoma, or nephrolithiasis 1

Treatment Evaluation Timeline

Evaluate treatment response within 2-3 months after initiation or change in treatment. 1 Key outcome measures include:

• Attack frequency (headache days per month) 1
• Attack severity 1
• Migraine-related disability 1

Headache calendars are extremely useful for capturing these measures and monitoring acute medication use. 1

When First-Line Treatment Fails

If first-line preventive medications fail after adequate trial (2-3 months at therapeutic doses), second-line options include: 1

• Flunarizine - 5-10 mg oral once daily (contraindicated in Parkinsonism or depression) 1
• Sodium valproate - 600-1,500 mg oral daily (absolutely contraindicated in females of childbearing potential) 1

Important consideration: Before concluding treatment has failed, review adherence and dosing optimization. 1 Some patients benefit from lower doses that have fewer adverse effects and therefore improve adherence. 1

Third-Line Options (Chronic Migraine Only)

OnabotulinumtoxinA (Botox) is only effective for chronic migraine (≥15 headache days per month) and should NOT be used for episodic headache. 7 This represents a third-line option after failure of oral preventive medications. 7

• Dose: 155-195 units to 31-39 sites every 12 weeks 1, 7
• Reduces headache days by approximately 1.9-3.1 days per month compared to placebo 7

Avoiding Common Pitfalls

Do not use opioids or butalbital-containing medications as these have high risk for medication-overuse headache and dependence. 1, 6 Reserve opioids only when other medications cannot be used and risk for abuse has been addressed. 1

Rescue medications (such as opioids or butalbital compounds) should only be considered for severe attacks failing other treatments, allowing the patient to get relief without emergency department visits. 1