Treatment of Chronic Headaches in Teenagers
Start with topiramate 50-100 mg orally daily as first-line preventive treatment for chronic headaches in teenagers, after ruling out red flags with targeted clinical evaluation. 1
Initial Diagnostic Evaluation
Before initiating treatment, screen for red flags that mandate neuroimaging:
- Thunderclap or sudden-onset headache 1
- Headache worsening when lying down or with Valsalva maneuver 1
- Focal neurological deficits 1
- Headache awakening patient from sleep or progressively worsening pattern 1
- Significant change in established headache pattern 1
If any red flags are present, obtain MRI with and without contrast before starting treatment; if MRI is normal but subarachnoid hemorrhage is suspected, perform lumbar puncture. 1 If no red flags are identified and neurologic examination is normal, imaging is not necessary. 1, 2
First-Line Preventive Treatment
Topiramate is the gold standard preventive medication for adolescents with chronic headaches, supported by Level A evidence from multiple class I trials and FDA approval. 1
- Dose: 50-100 mg orally daily 1
- Common adverse effects include cognitive inefficiency, paresthesias, fatigue, and weight loss 1
- Particularly suitable for patients with comorbid obesity due to weight loss effect 1
- Evaluate treatment response at 2-3 months after initiation 1
Second-Line Preventive Options
If topiramate fails or is not tolerated:
- Amitriptyline is the preferred second-line agent, especially beneficial when comorbid depression, anxiety, or sleep disturbances are present 1
- Adverse effects include dry mouth, sedation, weight gain, and constipation 1
- Beta-blockers (propranolol) may be useful if comorbid hypertension or tachycardia exists, but avoid in patients with asthma, diabetes, or bradycardia 1
Acute Treatment for Breakthrough Headaches
- NSAIDs (ibuprofen or naproxen) for mild to moderate attacks 1
- Triptans for moderate to severe attacks 1
- Limit acute medication use to prevent medication overuse headache (MOH) 1
Critical Comorbidity Assessment
Screen all teenagers with chronic headaches for psychiatric comorbidity, as adolescents have high rates of depression and anxiety that must be identified and treated. 1
- 71% of adolescents with chronic headaches have diagnosed psychiatric disorders including depression, anxiety, and PTSD 3
- Consider amitriptyline when both headache and mood disorder are present, as it treats both conditions 1
- Significant catastrophizing is present in 57% of patients, with 52% having mild to severe anxiety and 57% having depressive symptoms 3
Non-Pharmacologic Interventions
The American Academy of Neurology recommends offering evidence-based non-pharmacologic treatments: 1
- Cognitive-behavioral therapy (CBT) 1
- Biofeedback and relaxation training 1
- Regular aerobic exercise 1
- Progressive muscle relaxation, guided imagery, and meditation 1
Medication Overuse Headache Prevention
All patients must be asked about medication overuse, which increases headache frequency and can perpetuate chronic daily headache. 4
- Patients who overuse abortive medications should stop them entirely and transition to prophylactic treatment 4
- Implement a headache diary to track frequency, severity, triggers, and medication use 1
Common Pitfalls to Avoid
- Do not overlook that headaches may be manifestations of more complex pain syndromes (fibromyalgia, amplified musculoskeletal pain syndrome) requiring holistic approaches beyond conventional pharmacological management 3
- Do not prescribe valproate to female teenagers due to teratogenic effects 5
- Set realistic expectations for reduction of headache burden rather than complete elimination 1
- Recognize that 94% of adolescents with chronic headaches experience different types of pain besides headaches, suggesting broader pain processing dysfunction 3