Migraine Treatment in a 16-Year-Old
For a 16-year-old with migraine, start with ibuprofen 400-800 mg at headache onset as first-line therapy, and escalate to sumatriptan nasal spray 5-20 mg for moderate-to-severe attacks or when ibuprofen fails after 2-3 episodes. 1, 2
First-Line Acute Treatment
- Ibuprofen 7.5-10 mg/kg (typically 400-800 mg) is the preferred initial treatment for mild to moderate migraine in adolescents, as it demonstrates superior efficacy compared to acetaminophen alone 2, 3, 4
- Administer medication as early as possible during the attack—ideally when pain is still mild—to maximize efficacy 1, 2
- Acetaminophen 15 mg/kg (typically 1000 mg) can be used but is less effective than ibuprofen for pediatric migraine 2, 3
When to Escalate to Triptans
- If ibuprofen fails after 2-3 migraine episodes, or for moderate-to-severe attacks, use sumatriptan nasal spray 5-20 mg 1, 2
- Intranasal formulations are particularly useful when significant nausea or vomiting is present early in the attack 1, 2
- Sumatriptan nasal spray is effective and appropriate for adolescents, though subcutaneous formulations should be reserved for more severe cases 1, 3
Triptan Contraindications to Screen For
- Do not use triptans if the patient has uncontrolled hypertension, basilar or hemiplegic migraine, or cardiovascular risk factors 2
- Screen for ischemic heart disease, vasospastic coronary disease, or significant cardiovascular disease before prescribing 1
Adjunctive Antiemetic Therapy
- Add metoclopramide 10 mg (oral or IV) when nausea or vomiting is prominent, as it provides both antiemetic effects and synergistic analgesia 1, 2
- Consider nonoral routes of administration when significant nausea prevents oral medication absorption 1, 2
Critical Frequency Limitation
- Strictly limit all acute migraine 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, 2, 5
- If the patient requires acute treatment more than twice weekly, initiate preventive therapy immediately 1, 2
When to Consider Preventive Therapy
- Initiate preventive therapy if the patient has ≥2 migraine attacks per month causing disability for 3+ days, or uses rescue medication more than twice weekly 2, 6
- First-line preventive options for adolescents include propranolol (best safety data in children) or amitriptyline if propranolol is contraindicated 2, 4
- Avoid topiramate and valproate in adolescents due to potential adverse effects on cognition and development 2
Lifestyle Management (Essential Component)
- Maintain a consistent sleep schedule with adequate hours 2
- Ensure proper hydration throughout the day 2
- Encourage regular moderate-to-intense aerobic exercise 2
- Use a headache diary to identify and avoid specific triggers (foods, environmental factors, stress, weather changes) 2
- Address obesity if present, as it is a risk factor for migraine chronification 2
Medications to Absolutely Avoid
- Never use opioids (hydromorphone, oxycodone, meperidine) or butalbital-containing compounds for migraine treatment in adolescents, as they lead to dependency, rebound headaches, and loss of efficacy over time 1, 5
- These should only be considered in extremely rare circumstances when all other evidence-based treatments are contraindicated and the risk for abuse has been addressed 1
Red Flags Requiring Urgent Evaluation
- Obtain neuroimaging if the patient has headache worsened by Valsalva maneuver, headache that awakens from sleep, progressive worsening pattern, or abnormal neurologic examination findings 2
Common Pitfall to Avoid
- Do not abandon a triptan after a single failed attempt—if one triptan is ineffective, try a different triptan (such as rizatriptan or zolmitriptan), as failure of one does not predict failure of others 1, 2
- Each medication should be tried for 2-3 headache episodes before declaring treatment failure 2