What is the recommended preventive medication regimen for a 17-year-old female with migraines?

Migraine Prevention in a 17-Year-Old Female

For a 17-year-old female requiring migraine prevention, propranolol (80-240 mg/day) or topiramate (50-100 mg/day) are the recommended first-line options, with propranolol preferred due to its superior safety profile and established efficacy in adolescents. 1

Indications for Preventive Therapy

Your patient meets criteria for preventive treatment if she experiences any of the following: 1

• Two or more migraine attacks per month producing disability lasting 3 or more days
• Use of acute medications more than twice per week
• Failure of or contraindications to acute treatments
• Migraine attacks that significantly interfere with school, social activities, or daily functioning despite acute treatment

First-Line Medication Options

Propranolol (Preferred First Choice)

• Dosing: Start at 40 mg twice daily, titrate gradually to 80-240 mg/day in divided doses 1
• Advantages: Excellent safety profile in adolescents, well-established efficacy, no teratogenic risk if pregnancy occurs 1
• Contraindications: Asthma, cardiac failure, Raynaud disease, atrioventricular block, depression 1
• Common side effects: Fatigue, dizziness, nausea (generally well-tolerated) 1

Topiramate (Alternative First-Line)

• Dosing: Start at 25 mg at bedtime, increase by 25 mg weekly to target dose of 50-100 mg/day 1, 2
• Advantages: Proven efficacy, may cause weight loss (can be beneficial for some adolescents) 2, 3
• Critical warning: Absolutely contraindicated if pregnancy is possible—causes neural tube defects and other fetal harm 1
• Common side effects: Cognitive slowing, paresthesias, word-finding difficulty, kidney stones 1, 2

Timolol (Alternative Beta-Blocker)

• Dosing: 20-30 mg/day 1
• Similar efficacy and safety profile to propranolol 1

Second-Line Options

If first-line medications fail after adequate trial (2-3 months), consider: 1

Amitriptyline

• Dosing: Start 10 mg at bedtime, titrate to 30-150 mg/day 1
• Particularly effective if she has comorbid tension-type headaches, insomnia, or depression 1, 4
• Side effects: Weight gain, drowsiness, dry mouth, constipation 1
• Contraindications: Glaucoma, cardiac conduction abnormalities 1

Divalproex Sodium/Sodium Valproate

• Dosing: 500-1500 mg/day 1
• ABSOLUTELY CONTRAINDICATED in females of childbearing potential—known teratogen causing neural tube defects 1
• Should never be prescribed to a 17-year-old female unless she has documented infertility 1

Treatment Implementation Algorithm

1. Initiate at low dose: Start with the lowest recommended dose to minimize side effects 1, 3

2. Titrate gradually: Increase dose slowly every 1-2 weeks until therapeutic dose reached or side effects limit further increase 1, 3

3. Allow adequate trial period: Clinical benefit may take 2-3 months to manifest—do not abandon treatment prematurely 1, 3

4. Monitor with headache diary: Patient should track attack frequency, severity, duration, and medication use 1

5. Assess efficacy at 2-3 months: Treatment is successful if migraine frequency reduced by ≥50% 3, 5

6. Continue for 6-12 months if effective: After period of stability, attempt gradual taper to determine if continued treatment necessary 1, 6

Critical Pitfalls to Avoid

• Never prescribe valproate or topiramate without ensuring reliable contraception and pregnancy testing—both are teratogenic 1

• Do not allow continued overuse of acute medications—using acute treatments more than twice weekly will undermine preventive therapy effectiveness and cause medication-overuse headache 1

• Do not declare treatment failure before 2-3 months—premature discontinuation is common mistake, as benefits take time to manifest 1, 3

• Do not use multiple preventive medications simultaneously initially—start with monotherapy and optimize before considering combination therapy 6, 3

Special Considerations for Adolescent Females

• Menstrual migraine: If attacks are exclusively perimenstrual, consider short-term prevention with naproxen 500 mg twice daily or frovatriptan starting 2 days before expected menstruation for 5 days 1

• Contraception counseling: Essential if prescribing topiramate or if valproate is ever considered (though valproate should be avoided entirely) 1

• School impact: Emphasize that successful prevention improves academic performance and quality of life 3, 5

• Weight concerns: If weight gain is major concern, avoid amitriptyline and valproate; consider topiramate (with appropriate contraception) or beta-blockers 6, 3