Treatment of Chronic Headaches in Teenagers
For a teenager with chronic headaches, first rule out secondary causes with targeted evaluation for red flags, then initiate topiramate as first-line preventive therapy while addressing medication overuse, comorbid conditions, and implementing non-pharmacologic interventions.
Initial Diagnostic Approach
Rule Out Secondary Causes First
Before treating as primary headache disorder, evaluate for critical red flags requiring urgent neuroimaging 1, 2, 3:
- Thunderclap or sudden-onset headache 1, 2, 3
- Headache worsening when lying down or with Valsalva maneuver (suggests increased intracranial pressure) 1, 2, 3
- Focal neurological deficits (weakness, sensory changes, visual disturbances) 1, 2, 3
- Headache awakening patient from sleep or progressively worsening pattern 1, 2, 3
- Significant change in established headache pattern 1, 3
If any red flags present, obtain MRI with and without contrast before initiating treatment 3. If MRI is normal but subarachnoid hemorrhage suspected, perform lumbar puncture 3.
Assess for Medication Overuse Headache (MOH)
Frequent use of acute headache medications (≥10 days/month for triptans or ≥15 days/month for analgesics) can perpetuate chronic headaches 4, 5. This is a critical and often overlooked cause of treatment failure 6.
Preventive Pharmacologic Treatment
First-Line: Topiramate
Topiramate 50-100 mg orally daily is the first-line preventive treatment for chronic migraine in adolescents 4, 1. This recommendation is based on:
- Level A evidence with multiple class I trials demonstrating efficacy 4
- Cost-effectiveness compared to other options 4
- FDA approval for migraine prevention 4
Common adverse effects: Cognitive inefficiency, paresthesias, fatigue, weight loss 4. The weight loss effect makes it particularly appropriate for patients with obesity 4.
Second-Line Options
If topiramate fails or is not tolerated 4, 1, 2:
Amitriptyline (drug of second choice): Particularly beneficial if comorbid depression or sleep disturbances present 4, 2. Adverse effects include dry mouth, sedation, weight gain, constipation 4.
Beta-blockers (propranolol): Useful if comorbid hypertension or tachycardia 4, 2. Avoid in patients with asthma, diabetes, bradycardia 4.
Critical caveat: Valproate should be absolutely avoided in adolescent females of childbearing age due to teratogenic effects 4, 1, 3.
Advanced Therapies
For refractory cases after 2-3 failed preventive medications 4:
- OnabotulinumtoxinA (155 units): FDA-approved specifically for chronic migraine with large-scale trial evidence 4, 1
- CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab): Proven effective in treatment-resistant chronic migraine 4
Acute Treatment Management
For breakthrough headaches 1, 7:
- Mild to moderate attacks: NSAIDs (ibuprofen, naproxen) 1, 7
- Moderate to severe attacks: Triptans 1, 7
Critical warning: Limit acute medication use to prevent MOH. Educate patients that overuse of acute medications (even over-the-counter) can worsen headache frequency 4, 5.
Non-Pharmacologic Interventions
These should be offered to all patients and are evidence-based 4, 2, 5:
- Cognitive-behavioral therapy (CBT) 4, 5, 8
- Biofeedback and relaxation training 4, 5, 8
- Regular aerobic exercise (40 minutes three times weekly, as effective as topiramate in trials) 4, 2
- Progressive muscle relaxation, guided imagery, meditation 4, 5
Address Comorbid Conditions
Adolescents with chronic headaches have high rates of psychiatric comorbidity that must be identified and treated 4, 9:
- Depression and anxiety: Present in 52-57% of adolescents with chronic headaches 9. Consider amitriptyline as it treats both headache and mood disorder 4.
- Sleep disturbances: Common and exacerbate headaches 4, 6
- Autonomic dysfunction: May coexist 6
Recent data shows 71% of adolescents with chronic headaches have diagnosed psychiatric disorders, with 16% having history of self-harm 9. This underscores the need for comprehensive mental health screening.
Recognize Complex Pain Syndromes
A 2024 study found that 39% of adolescents referred for "chronic headaches" actually had more complex conditions 9:
- Fibromyalgia or amplified musculoskeletal pain syndrome (AMPS): 30% combined 9
- Autism with sensory integration problems: 9% 9
- Major depression as primary driver: 9% 9
If conventional headache treatment fails, consider referral to pain specialist for evaluation of these broader pain syndromes 9.
Monitoring and Follow-Up
- Implement headache diary to track frequency, severity, triggers, and medication use 4, 2
- Evaluate treatment response at 2-3 months after initiating or changing preventive therapy 1, 2
- Set realistic expectations: Recovery may be gradual, and the goal is reduction (not elimination) of headache burden 4, 8
- Refer to headache specialist if diagnosis uncertain, no improvement after 2-3 preventive trials, or significant disability persists 4, 2
Critical Pitfalls to Avoid
Polypharmacy: Adolescents with chronic headaches are often prescribed multiple medications (average 4.5 different drugs) without benefit 9. Use systematic approach with adequate trials before adding agents.
Missing medication overuse: This perpetuates the cycle and must be addressed before preventive therapy can work 4, 5, 6.
Ignoring psychiatric comorbidity: Treating headache alone without addressing depression/anxiety leads to poor outcomes 4, 9, 6.
Premature neuroimaging: If no red flags present, imaging is unnecessary and may increase anxiety 1, 2.
Focusing solely on pharmacology: Non-drug therapies and lifestyle modifications are essential components of successful management 4, 2, 5.