What is the appropriate evaluation and treatment approach for a 16-year-old female patient presenting with headaches, considering potential menstrual-related or migraine causes?

Evaluation and Management of Headaches in a 16-Year-Old Female

For a 16-year-old female presenting with headaches, begin with a focused clinical assessment to distinguish primary headache disorders (most likely migraine or tension-type) from secondary causes, then treat acutely with NSAIDs or combination analgesics, and consider preventive therapy if headaches occur more than 2 days per week. 1

Initial Clinical Assessment

Obtain a detailed headache history focusing on specific characteristics that differentiate primary from secondary causes:

• Temporal pattern: Determine relationship to menstrual cycle, as hormonal fluctuations commonly trigger migraine in adolescent females 1
• Pain characteristics: Assess for throbbing quality, unilateral location, duration (hours to days), and severity that interferes with function 1
• Associated symptoms: Screen for nausea/vomiting, photophobia, phonophobia, visual aura, or other sensory changes 1
• Triggers: Identify stress, sleep patterns (including headaches awakening from sleep), missed meals, specific foods/beverages, environmental exposures (perfumes, smoke), and weather changes 1
• Family history: Document headache disorders in relatives, as migraine has strong genetic component 1
• Medication use: Assess current over-the-counter or prescribed medications, their effectiveness, and frequency of use 1

Red Flags Requiring Neuroimaging

Neuroimaging is NOT routinely warranted in adolescents with normal neurologic examination and typical primary headache features. 1 However, consider imaging if:

• Headache worsened by Valsalva maneuver 1
• Headache awakening patient from sleep 1
• Progressive worsening pattern 1
• Any abnormal neurologic examination findings 1
• Atypical features not meeting strict migraine criteria 1

Acute Treatment Strategy

For mild to moderate headaches, initiate treatment as early as possible during an attack to maximize efficacy:

• First-line: NSAIDs such as ibuprofen 400-800 mg or naproxen sodium 500-825 mg at headache onset 1
• Alternative: Combination of aspirin, acetaminophen, and caffeine (acetaminophen alone is ineffective for migraine) 1
• Critical limitation: Restrict acute medication use to no more than 2 days per week to prevent medication-overuse headache 1

Avoid opioid analgesics and butalbital-containing compounds in adolescents, as these lead to dependency, rebound headaches, and loss of efficacy. 1

When to Initiate Preventive Therapy

Preventive therapy should be considered if the patient requires acute treatment more than 2 days per week (equivalent to >2 headaches per week). 1

First-line preventive options for adolescent females include:

• Beta-blockers: Propranolol or metoprolol, particularly if no contraindications like asthma 1
• Topiramate: Effective but monitor for cognitive side effects and avoid in pregnancy risk 2
• Amitriptyline: Consider if comorbid anxiety or sleep disturbance 2

Menstrual-Related Migraine Considerations

In adolescent females, assess temporal relationship between headaches and menstrual cycle, as menstrual migraine is common in this population. 1 If pattern emerges:

• Consider short-term prophylaxis with NSAIDs starting 2-3 days before expected menses 1
• Hormonal interventions may be considered in consultation with gynecology for refractory cases

Treatment Goals and Monitoring

Establish clear treatment objectives:

• Treat attacks rapidly and consistently without recurrence 1
• Restore ability to function and attend school 1
• Minimize need for rescue medications 1
• Optimize self-care and trigger management 1
• Avoid medication-overuse headache through careful monitoring 1

Critical Pitfalls to Avoid

• Do not assume benign primary headache without proper red flag screening, as secondary causes, though rare, can occur in adolescents 3, 4
• Do not allow frequent analgesic use (≥15 days/month for NSAIDs or ≥10 days/month for triptans), as this creates medication-overuse headache requiring withdrawal and preventive therapy 1
• Do not prescribe opioids or butalbital compounds for chronic headache management in adolescents due to dependency risk and rebound phenomena 1
• Do not overlook comorbid conditions such as anxiety, depression, or sleep disorders that commonly coexist with migraine and may require concurrent treatment 1