What is the step-wise approach to managing headaches in a 16-year-old?

Stepwise Management of Headaches in a 16-Year-Old

Start with NSAIDs (ibuprofen 400-800 mg or naproxen sodium 550 mg) as first-line acute treatment, escalate to triptans if NSAIDs fail after adequate trials, and initiate preventive therapy early if headaches occur ≥2 days per month despite optimized acute treatment. 1, 2

Initial Assessment and Education

Before prescribing medication, provide comprehensive education about headache as a disease entity and set realistic expectations—the goal is control and reduced disability, not cure 1. In adolescents aged 12-17 years, migraine attacks are often shorter in duration (2-72 hours rather than 4-72 hours in adults), more frequently bilateral rather than unilateral, and gastrointestinal symptoms are commonly prominent 1. Obtain history from both the adolescent and parents, as parents often provide more reliable accounts of symptoms and lifestyle factors 1.

Key red flags to exclude secondary headaches include: thunderclap onset, atypical aura, head trauma, progressive worsening, headache aggravated by maneuvers that raise intracranial pressure, onset with sneezing/coughing/exercise, fever, neck stiffness, focal neurological symptoms, or weight loss 1. If any red flags are present, neuroimaging is mandatory before proceeding with treatment 1.

Step 1: Acute Treatment Algorithm

First-Line: NSAIDs

• Ibuprofen is the recommended first-line medication at weight-appropriate doses 1, 3
• Alternative NSAIDs include acetylsalicylic acid (650-1000 mg) or diclofenac potassium 1
• Paracetamol has inferior efficacy and should only be used if NSAIDs are contraindicated 1
• Critical timing: Advise taking medication early when headache is still mild, not waiting until pain is severe 1

Second-Line: Triptans

• If NSAIDs provide inadequate relief after adequate trials (defined as failure in at least 3 consecutive attacks), escalate to triptans 1
• For adolescents 12-17 years, nasal spray formulations of sumatriptan and zolmitriptan are most effective 1
• Take triptans early when headache is mild, but NOT during aura phase 1
• If one triptan fails, try alternative triptans as response varies between agents 1

Adjunct Therapy for Nausea

• Domperidone can be used for nausea in adolescents aged 12-17 years, though oral administration is unlikely to prevent vomiting 1
• Metoclopramide 10 mg or prochlorperazine 10 mg are alternatives 1, 2

Medications to Avoid

• Never use oral ergot alkaloids, opioids, or barbiturates—they have questionable efficacy, considerable adverse effects, and risk of dependency 1, 4
• Avoid frequent repeated use of any acute medication (>10-15 days/month) due to medication overuse headache (MOH) risk 1, 5

Step 2: When to Initiate Preventive Therapy

Begin preventive therapy if headaches occur ≥2 days per month despite optimized acute treatment, or if attacks cause significant disability 1, 2. The American Academy of Neurology recommends initiating preventive therapy early rather than waiting for multiple failed acute treatments, particularly in new-onset migraine with aura 2.

First-Line Preventive Options

Propranolol (beta-blocker):

• Dose: Start low and titrate based on response 1, 4
• Particularly useful if comorbid hypertension or anxiety 4
• Best safety profile in adolescents 1

Topiramate:

• Dose: 50-100 mg daily 4
• Especially beneficial if patient is overweight/obese 1, 4
• Assess efficacy after 2-3 months at therapeutic dose 1, 4

Amitriptyline:

• Dose: 10-100 mg at night 4
• Particularly useful if comorbid depression, anxiety, or sleep disturbances 1, 4
• Alternative: nortriptyline if anticholinergic side effects are problematic 4

Second-Line Options

• Candesartan (angiotensin receptor blocker): First-line option per some guidelines, particularly if hypertensive 2, 4
• Flunarizine: 5-10 mg once daily, avoid if depression or Parkinsonism 4

Medications Contraindicated in Adolescents

• Sodium valproate is absolutely contraindicated in females of childbearing potential due to teratogenicity 1, 2

Step 3: Lifestyle Modifications (Essential Foundation)

Non-pharmacological measures are MORE important than pharmacotherapy in adolescents 3, 6. These include:

• Regular sleep schedule: Both sleep deprivation and excessive sleep trigger migraines 6, 7
• Regular meal timing and adequate hydration 4, 6
• Limited caffeine consumption (excessive intake is a trigger, but abrupt withdrawal also triggers headaches) 4, 6
• Regular physical activity to prevent obesity 6
• Stress management and relaxation training 3, 6, 8
• Avoid tobacco and alcohol 4, 6

Step 4: Treatment Duration and Reassessment

• Assess efficacy of oral preventive medications after 2-3 months at therapeutic dose 1, 4
• If effective, continue for 6-12 months, then consider pausing to determine if preventive therapy can be stopped 4
• Educate that efficacy is rarely immediate—it takes weeks to months 1, 4
• Failure of one preventive medication does not predict failure of other drug classes 4

Step 5: When to Refer to Specialist

Refer if:

• Acute medication provides insufficient pain relief despite optimized trials 1
• Preventive therapy fails after adequate trials of first-line agents 1
• Chronic daily headache develops (≥15 days/month for ≥3 months) 1, 8
• Medication overuse headache is suspected or confirmed 1, 5

Critical Pitfalls to Avoid

• Do not abandon treatment prematurely—efficacy takes weeks to months to establish 1, 4
• Do not allow frequent acute medication use—this risks medication overuse headache and central sensitization leading to chronic daily headache 1, 5, 8
• Do not use opioids or barbiturates—they cause dependency, rebound headaches, and loss of efficacy 1, 4
• Screen for and address comorbidities (anxiety, depression, sleep disturbances, obesity) as they impair treatment effectiveness 1, 5, 8
• Do not conflate trigger factors with aggravating factors—true triggers are often self-evident, and excessive trigger avoidance can damage quality of life 1