What is the initial treatment approach for a 14-year-old patient presenting to the Emergency Room (ER) with a migraine headache?

ER Treatment for Migraine in a 14-Year-Old

Start with ibuprofen 400-800 mg (weight-appropriate dosing) plus metoclopramide 10 mg IV as first-line therapy for acute migraine in adolescents presenting to the emergency room. 1

First-Line IV Treatment Protocol

For moderate to severe migraine in the ER setting:

• Administer ibuprofen at weight-appropriate doses (typically 400-800 mg) as the American Academy of Neurology recommends this as first-line treatment for adolescents with migraine 1
• Add metoclopramide 10 mg IV for both its antiemetic properties and direct analgesic effects through central dopamine receptor antagonism 2
• Administer medication as early as possible during the attack to maximize efficacy—effectiveness depends critically on timing 1

Alternative first-line combination:

• Ketorolac 30 mg IV plus metoclopramide 10 mg IV provides rapid pain relief with minimal rebound headache risk 2
• Ketorolac has relatively rapid onset with approximately 6 hours duration, making it ideal for severe migraine abortive therapy 2

When First-Line Treatment Fails

If ibuprofen fails after 2-3 consecutive attacks or if the patient presents with severe, disabling migraine:

• Escalate to triptans for moderate-to-severe migraine 1
• Intranasal sumatriptan 5-20 mg is particularly effective when significant nausea or vomiting is present 1, 2
• Rizatriptan is useful in adolescents as it comes in an absorbable wafer form, beneficial when nausea develops 1

Critical contraindications for triptans:

• Do NOT use if the patient has uncontrolled hypertension, basilar or hemiplegic migraine, or cardiovascular risk factors 1

Adjunctive Nausea Management

If nausea or vomiting is prominent:

• Domperidone can be used for nausea in adolescents aged 12-17 years, though oral administration is unlikely to prevent vomiting 1
• Use a nonoral route of administration and add an antiemetic when nausea is significant 1
• Metoclopramide is safe and effective for migraine-associated nausea in this age group 1

Alternative IV Options

If standard therapy is contraindicated or ineffective:

• Prochlorperazine 10 mg IV effectively relieves headache pain and is comparable to metoclopramide in efficacy 2
• Dihydroergotamine (DHE) intranasal or IV has good evidence for efficacy as monotherapy 2

Critical Medication Overuse Warning

Limit acute treatment to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily chronic headaches 1

Red Flags Requiring Neuroimaging

Obtain neuroimaging if any of the following are present:

• Headache worsened by Valsalva maneuver 1
• Headache that awakens from sleep 1
• Progressive worsening pattern 1
• Abnormal neurologic examination findings 1

Disposition and Follow-Up Planning

Before discharge:

• Evaluate for preventive treatment if the patient has ≥2 migraine attacks per month causing disability for 3+ days, or uses rescue medication more than twice weekly 1
• Propranolol is the first-line preventive medication with the best safety data in children and adolescents 1
• Provide a headache diary to monitor frequency for 8-12 weeks when assessing treatment response 1

Common Pitfalls to Avoid

Do not allow frequent use of acute medications in response to persistent headaches—this creates medication-overuse headache 1

Bed-rest alone might suffice in children with short-duration attacks, so avoid unnecessary medication exposure when possible 1

Avoid opioids completely as they can lead to dependency, rebound headaches, and eventual loss of efficacy 2

Family members and teachers should be educated about the condition and management plan, as active help from both is usually necessary 1