What medications can be used for acute treatment of migraine in an adolescent female less than 18 years old?

Acute Migraine Treatment in Adolescent Girls Under 18

Start with ibuprofen 400-800 mg at migraine onset as first-line therapy, and escalate to triptans (sumatriptan/naproxen combination, zolmitriptan nasal spray, sumatriptan nasal spray, rizatriptan ODT, or almotriptan oral) for moderate to severe attacks or when ibuprofen fails after 2-3 episodes. 1

First-Line Treatment: NSAIDs

• Ibuprofen 7.5-10 mg/kg (typically 400-800 mg) is the primary acute treatment for adolescent migraine, with evidence showing pain freedom in children and adolescents (RR 1.87,95% CI 1.15 to 3.04). 1, 2
• Acetaminophen 15 mg/kg (typically 1000 mg) can be used but has weaker evidence than ibuprofen in pediatric populations. 3, 4
• Counsel the patient to take medication early in the attack while pain is still mild for maximum effectiveness. 1

Second-Line Treatment: Triptans for Adolescents

When ibuprofen fails after 2-3 migraine episodes, escalate to triptans, which show moderate quality evidence with pain freedom rates significantly higher than placebo (RR 1.32,95% CI 1.19 to 1.47, NNTB 6 in adolescents). 1, 2

Recommended triptan options for adolescents include:

• Sumatriptan/naproxen sodium combination (preferred): Most effective option with RR 3.25 (95% CI 1.78 to 5.94, NNTB 6). 1, 2
• Zolmitriptan nasal spray 5 mg: FDA-approved for adolescents in Europe. 1, 3
• Sumatriptan nasal spray 5-20 mg: FDA-approved for adolescents, particularly useful when nausea/vomiting present. 1, 3, 4
• Rizatriptan ODT 10 mg: FDA-approved for ages 6-17 years in the USA. 1, 3
• Almotriptan oral: FDA-approved for adolescents in the USA. 1, 3

Critical Frequency Limitation

Strictly limit all acute medications to no more than 2 days per week (10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 1, 5, 6

If First Triptan Fails

Try a different triptan before abandoning the class entirely, as failure of one triptan does not predict failure of others—each triptan should be tried for 2-3 headache episodes before switching. 1

Route Selection Based on Symptoms

• For rapid pain escalation or severe nausea/vomiting: Use non-oral triptans (nasal spray formulations preferred over oral). 1
• For nausea/vomiting: Add antiemetic (metoclopramide 10 mg or prochlorperazine) or use non-oral triptan formulation. 1

Safety Considerations Specific to Adolescent Females

Discuss teratogenic effects of certain preventive medications (topiramate, valproate) if considering preventive therapy, and advise effective birth control methods plus folate supplementation. 1

When to Initiate Preventive Therapy

If the adolescent requires acute treatment more than 2 days per week, initiate preventive therapy immediately to reduce attack frequency and restore responsiveness to acute treatments. 1, 5

Medications to Avoid

Never use opioids or butalbital-containing compounds as they have questionable efficacy, cause dependency, lead to rebound headaches, and result in medication-overuse headache with high risk of chronification. 5, 6

Common Pitfall to Avoid

The most critical error is allowing patients to increase frequency of acute medication use beyond twice weekly, which creates a vicious cycle of medication-overuse headache—instead, transition to preventive therapy while optimizing the acute treatment strategy. 5, 6

Minor Adverse Events with Triptans

Triptans are associated with increased risk of minor (non-serious) adverse events in adolescents (RD 0.13,95% CI 0.08 to 0.18, NNTH 8), but no serious adverse events have been reported in pediatric trials. 2