What are the recommended management and treatment options for a 12-year-old male with migraines?

Migraine Management in a 12-Year-Old Male

For a 12-year-old boy with migraine, start with ibuprofen 10 mg/kg (up to 400-800 mg) at the first sign of headache, adding metoclopramide if nausea is present, and initiate propranolol for prevention if he experiences ≥2 disabling attacks per month. 1

Acute Treatment Algorithm

First-Line: NSAIDs

• Ibuprofen 7.5-10 mg/kg (maximum 400-800 mg) is superior to acetaminophen alone and should be the initial treatment for mild to moderate migraine attacks in children. 1, 2
• Administer medication as early as possible during the attack—ideally when pain is still mild—to maximize efficacy. 1
• Acetaminophen 15 mg/kg can be used but is less effective than ibuprofen or combination therapy. 1, 2

Adding Antiemetics for Nausea

• If nausea or vomiting is prominent, add metoclopramide, which is safe and effective for migraine-associated nausea in children. 1
• Consider nonoral routes of administration (rectal suppository or intranasal formulations) if vomiting prevents oral medication absorption. 1

Second-Line: Triptans (Age-Appropriate Consideration)

• Sumatriptan nasal spray (5-20 mg) is effective for adolescents and can be considered for a 12-year-old with moderate to severe attacks when NSAIDs fail after 2-3 episodes. 3, 2, 4
• Triptans should not be used if the child has uncontrolled hypertension, basilar or hemiplegic migraine, or cardiovascular risk factors. 1
• Intranasal formulations are particularly useful when significant nausea or vomiting is present early in the attack. 3

Critical Frequency Limitation

• Limit all acute medications to no more than 2 days per week (10 days per month) to prevent medication-overuse headache, which can paradoxically increase headache frequency and lead to daily headaches. 1

Preventive Therapy Indications

When to Initiate Prevention

Evaluate for preventive treatment if the child meets any of these criteria: 1

• Two or more migraine attacks per month causing disability for 3+ days
• Rescue medication use more than twice weekly
• Contraindication to or failure of acute treatments
• Presence of uncommon migraine conditions

First-Line Preventive Medication

• Propranolol is the evidence-based first choice for preventive therapy in children, with the best safety data in this age group. 1
• Amitriptyline can be used if propranolol is contraindicated. 1
• Avoid topiramate, valproate, and candesartan due to potential adverse effects on growth, development, and cognition in children. 1

Lifestyle Management (Essential Component)

Sleep and Hydration

• Maintain a consistent sleep schedule with adequate hours for age (9-12 hours for a 12-year-old). 1
• Ensure proper hydration throughout the day with regular fluid intake. 1

Physical Activity and Trigger Identification

• Encourage regular moderate-to-intense aerobic exercise, which can reduce migraine frequency. 1, 5
• Use a headache diary for 8-12 weeks to identify specific triggers such as foods, environmental factors, stress, and weather changes. 1
• Once triggers are identified, work on avoidance strategies and coping skills for triggers that cannot be avoided. 6, 7

Weight and Diet Management

• Address obesity if present, as it is a risk factor for migraine chronification. 3, 5
• Ensure regular meals to avoid hypoglycemia as a trigger. 5

Red Flags Requiring Urgent Evaluation

Obtain neuroimaging if any of these features are present: 1

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

Monitoring and Escalation Strategy

Initial Management Period

• Monitor headache frequency with a diary for 8-12 weeks. 1
• If ≥2 attacks per month with significant disability persist despite optimized acute treatment, initiate preventive therapy with propranolol. 1

When Acute Treatment Fails

• If ibuprofen fails after 2-3 migraine episodes, escalate to sumatriptan nasal spray for moderate to severe attacks. 1, 2
• If one triptan fails, try a different triptan formulation, as failure of one does not predict failure of others. 3

Non-Pharmacological Adjuncts

Consider these evidence-based approaches as adjuncts or stand-alone treatments: 3, 7

• Biofeedback and relaxation training (first-line behavioral interventions with strong evidence)
• Cognitive-behavioral therapy for stress management
• Acupuncture (recent positive findings from randomized trials)

Nutraceuticals with Evidence

• Riboflavin (vitamin B2) has shown efficacy in more than one randomized trial and is a potentially useful first-line preventive intervention. 3, 7
• Magnesium supplementation can be helpful as an adjunct. 6

Common Pitfalls to Avoid

• Never allow frequent use of acute medications (>2 days/week) without initiating preventive therapy, as this creates medication-overuse headache. 1
• Do not use opioids or butalbital-containing compounds for pediatric migraine—these have questionable efficacy and lead to dependency and rebound headaches. 1
• Do not abandon treatment after a single failed medication trial; each medication should be tried for 2-3 headache episodes before switching. 3
• Preventive medications require adequate trial duration (2-3 months minimum) before declaring treatment failure. 3