How to manage an 18-year-old with daily unilateral migraines of mild to moderate intensity and normal MRI/MRA brain?

Management of Daily Unilateral Migraines in an 18-Year-Old

Start with NSAIDs (ibuprofen 800mg or diclofenac) as first-line acute treatment, taken early when headache is still mild, and immediately initiate preventive therapy given the near-daily frequency. 1, 2

Acute Treatment Strategy

First-Line Acute Medication

• Use NSAIDs as the primary acute treatment: ibuprofen 800mg every 6 hours as needed or diclofenac potassium 1, 2
• Acetylsalicylic acid (aspirin) is another evidence-based first-line option 1
• Critical timing: Administer medication early in the attack when headache is still mild to maximize efficacy 1
• Avoid acetaminophen alone as it has limited efficacy for migraine 1

Second-Line Acute Medication

• Triptans are indicated when NSAIDs provide inadequate relief 1
• All triptans have well-documented effectiveness; choice depends on availability and cost 1
• Triptans work best when taken early during mild headache, not during aura phase 1
• If one triptan fails, others may still provide relief 1
• At 18 years old, this patient is appropriate for triptan use (approved for adults ≥18 years) 3

Adjunctive Treatment

• Add an antiemetic (metoclopramide or prochlorperazine) if nausea is present to treat associated symptoms and improve gastric motility 1, 2
• Metoclopramide given intravenously may serve as monotherapy for acute attacks, particularly when nausea/vomiting is prominent 1

Preventive Therapy - ESSENTIAL Given Frequency

Preventive therapy is mandatory in this patient because she has near-daily headaches (>15 days/month), which far exceeds the threshold of ≥2 headache days per month for initiating prophylaxis 1, 4, 2

First-Line Preventive Options

• Topiramate: Evidence-based first choice due to proven efficacy and lower cost 1, 2
• Beta-blockers (propranolol or metoprolol): Effective preventive options 4
• Amitriptyline: Particularly useful if comorbid sleep disturbances exist 4

Important Consideration

• Benefits of preventive medications may take several weeks to become apparent; patient adherence is critical 2
• Consider discontinuing preventive medication after 3-6 months of stability to determine if prophylaxis is still needed 4

Critical Warning: Medication Overuse Headache

This patient is at extremely high risk for medication overuse headache (MOH) given the near-daily frequency 1, 2

• MOH develops from regular overuse of acute medications: ≥15 days/month for NSAIDs 1, 2
• Acute treatment must be strictly limited to no more than 2 days per week to prevent MOH 1
• If MOH develops, abrupt withdrawal of the overused medication is necessary (except for opioids) 1
• This is why preventive therapy is non-negotiable in this case - it reduces attack frequency and prevents the need for frequent acute medication use 1

Lifestyle Modifications and Non-Pharmacological Approaches

Essential Lifestyle Changes

• Maintain regular sleep patterns: Consistent sleep schedule to avoid sleep disturbances as a trigger 2, 5, 6
• Regular meals and adequate hydration: Avoid fasting, which is a verified migraine trigger 2, 6
• Regular exercise: 40 minutes three times weekly has been shown to be as effective as topiramate for migraine prevention 4, 2, 5
• Stress management: Address stress as a common trigger 2, 6

Behavioral Interventions

• Cognitive behavioral therapy (CBT), relaxation training, or biofeedback have demonstrated efficacy for migraine management 4, 2, 7
• These are considered first-line preventive options with strong evidence from randomized trials 7

Trigger Identification

• Maintain a headache diary to identify specific triggers and monitor treatment effectiveness 4, 2
• Common triggers include stress, menstrual cycle changes, weather changes, sleep disturbances, and certain foods 6
• However, true trigger factors are often self-evident, and their role should not be overemphasized 1
• Avoid unnecessary avoidance behavior that can damage quality of life 1

Monitoring and Follow-Up

• Schedule regular follow-up visits to monitor headache frequency, severity, and response to treatment 4, 2
• Use standardized assessment tools like the Headache Impact Test (HIT-6) to monitor progress 4
• Adjust treatment based on response and tolerability 4, 2

Key Clinical Pitfalls to Avoid

1. Do not use opioids or butalbital-containing medications due to risk of dependency, rebound headaches, and loss of efficacy 1, 2
2. Do not delay preventive therapy - with near-daily headaches, this patient needs prophylaxis immediately, not just acute treatment 1
3. Do not allow frequent acute medication use - strictly limit to prevent MOH 1, 2
4. Educate the patient that migraine is a chronic disease requiring ongoing management, not just attack treatment 1
5. Set realistic expectations: The goal is to return control from the disease to the patient, reducing attack-related disability to allow continuation of life with minimal hindrance 1