What is the best treatment approach for a 15-year-old male with no prior history of similar symptoms, presenting with a recent onset of symptoms suggestive of migraine or episodic disorder?

Treatment of New-Onset Episodic Migraine in a 15-Year-Old Male

Critical First Step: Rule Out Secondary Causes

Before initiating any migraine treatment in this adolescent with new-onset headaches, you must immediately evaluate for secondary causes including subarachnoid hemorrhage, meningitis, intracranial mass, or other life-threatening conditions. 1

• New-onset headache with irritability is a red flag requiring urgent evaluation for secondary causes 1
• Obtain urgent non-contrast head CT if any red flags are present, including new onset in combination with altered consciousness, progressive worsening, or focal neurological findings 1
• If CT is negative but suspicion remains high, proceed to lumbar puncture with spectrophotometric analysis for xanthochromia 1

Acute Treatment Strategy (Once Secondary Causes Excluded)

For moderate to severe headache attacks, initiate combination therapy with a triptan plus NSAID as first-line treatment. 1

• For mild to moderate attacks, NSAIDs alone or acetaminophen combined with NSAID are appropriate 1
• If nausea or vomiting accompanies the headache, add metoclopramide or prochlorperazine as adjunctive antiemetic 1
• Strictly avoid opioids and butalbital-containing compounds, as these lead to dependency and medication overuse headache 1, 2
• Limit acute medication use to no more than twice per week (approximately 8-10 days per month) to prevent medication overuse headache 2

When to Initiate Preventive Therapy

Given only 2 weeks of symptom duration, preventive therapy is not yet indicated unless specific high-risk features are present. 3, 4

Preventive therapy should be considered if: 4, 5

• Headaches occur more than 2 times per week
• Attacks significantly interfere with daily routine despite optimized acute treatment
• The patient is already overusing acute medications (>2 days per week)
• Headaches continue to impair quality of life on ≥2 days per month despite optimized acute treatment 1

First-Line Preventive Options (If Indicated)

If preventive therapy becomes necessary, initiate monotherapy with a beta-blocker (metoprolol or propranolol), valproate, venlafaxine, or amitriptyline as first-line options. 3

• Beta-blockers (metoprolol or propranolol) are preferred first-line agents due to favorable tolerability profile compared to other options 3
• Start at a low dose and gradually increase until desired outcomes are achieved 3
• Allow 2-3 months for adequate trial before declaring treatment failure 3, 5
• Switch medications if inadequate response occurs during this trial period, or earlier if adverse effects develop 3

Second-Line Preventive Options

If first-line agents are not tolerated or produce inadequate response, use monotherapy with a CGRP antagonist-gepant (atogepant or rimegepant) or CGRP monoclonal antibody (eptinezumab, erenumab, fremanezumab, or galcanezumab). 3

• CGRP-based therapies may reduce migraine frequency (0.80 fewer days per month) and acute medication intake (1.02 fewer days per month) compared to topiramate 3
• These agents also have fewer discontinuations due to adverse events compared to topiramate 3

Third-Line Preventive Option

Use topiramate only after trials of both first-line agents and CGRP-based therapies have failed. 3

• Topiramate is relegated to third-line due to higher discontinuation rates from adverse events compared to beta-blockers and CGRP-based therapies 3

Critical Monitoring and Education

• Maintain a headache diary to determine treatment efficacy, identify analgesic overuse, and monitor migraine progression 3
• Emphasize that adherence is crucial, as improvement occurs gradually after initiation, with effects becoming apparent after the first few weeks 3
• Educate on lifestyle modifications: hydration, regular meals, sufficient sleep, physical activity, stress management, and trigger identification 2
• Reevaluate preventive treatment balance of benefits, harms, and costs regularly with the patient 3

Special Considerations for Adolescents

• In adolescents of childbearing potential, discuss adverse effects of pharmacologic treatments during pregnancy and lactation before initiating therapy 3
• Valproate carries significant teratogenic risks and should be avoided in females of childbearing potential unless no other options exist 3
• Cost considerations are important, as economic circumstances may vary significantly in this age group 3