Migraine Management in Teenagers
Acute Treatment Algorithm
For mild to moderate migraine attacks, start with NSAIDs (ibuprofen 400-800 mg or naproxen sodium 500-825 mg) as first-line therapy; for moderate to severe attacks or when NSAIDs fail after 2-3 episodes, escalate immediately to triptans. 1
First-Line Acute Treatment
NSAIDs are the initial treatment of choice for mild to moderate migraine in adolescents, with ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 1000 mg demonstrating the strongest evidence for efficacy. 2, 1
The combination of acetaminophen 1000 mg + aspirin 500-1000 mg + caffeine 130 mg is an effective alternative first-line option, achieving pain reduction to mild or none in 59.3% of patients at 2 hours. 1
Begin treatment as early as possible during the attack while pain is still mild to maximize effectiveness. 1, 3
Second-Line: Triptans for Moderate to Severe Attacks
Triptans are first-line therapy for moderate to severe migraine or when NSAIDs fail after 2-3 headache episodes. 1, 3
Oral triptans with strong evidence include sumatriptan 50-100 mg, rizatriptan 10 mg, naratriptan, and zolmitriptan 2.5-5 mg. 2, 1
Rizatriptan 10 mg reaches peak concentration in 60-90 minutes, making it the fastest oral triptan and particularly suitable for adolescents. 1
If one triptan fails after 2-3 episodes, try a different triptan before abandoning the class entirely, as failure of one does not predict failure of others. 1
For severe nausea or vomiting, consider intranasal sumatriptan 5-20 mg or subcutaneous sumatriptan 6 mg for rapid onset within 15 minutes. 1
Adjunctive Antiemetic Therapy
- Add metoclopramide 10 mg orally 20-30 minutes before the analgesic to provide synergistic analgesia and improve absorption, not just for nausea control. 1
Critical Frequency Limitation
Limit all acute migraine 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, 4
If the teenager requires acute treatment more than twice weekly, immediately initiate preventive therapy rather than increasing frequency of acute medications. 1, 4
Medications to Absolutely Avoid
- Never prescribe opioids (hydrocodone, oxycodone, codeine) or butalbital-containing compounds for adolescent migraine, as they have questionable efficacy, lead to dependency, cause rebound headaches, and result in loss of efficacy over time. 1, 4
Preventive Treatment Algorithm
Initiate preventive therapy when the teenager experiences ≥2 migraine attacks per month with disability lasting ≥3 days, uses acute medications more than twice weekly, or has contraindications to acute treatments. 2, 3, 4
Indications for Preventive Therapy
Two or more attacks per month producing disability lasting 3 or more days per month. 2, 3
Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura, or migrainous infarction). 2
First-Line Preventive Medications
β-blockers without intrinsic sympathomimetic activity are the preferred first-line preventive agents for adolescents.
Propranolol 80-240 mg/day has the strongest evidence from multiple randomized controlled trials and is FDA-approved for migraine prevention. 2, 3, 4
Timolol 20-30 mg/day also has strong evidence for efficacy. 2, 3
Metoprolol, atenolol, and nadolol have moderate evidence supporting their use. 2
Avoid β-blockers with intrinsic sympathomimetic activity (acebutolol, alprenolol, oxprenolol, pindolol), as they are ineffective for migraine prevention. 2
Common adverse effects include fatigue, depression, nausea, dizziness, and insomnia, though these are generally well tolerated. 2
Alternative First-Line Options
Amitriptyline 30-150 mg/day is preferred when the teenager has comorbid depression, anxiety, sleep disturbances, or mixed migraine and tension-type headache. 2, 3
Drowsiness, weight gain, and anticholinergic symptoms are frequently reported with amitriptyline. 2
Anticonvulsants (Use with Extreme Caution in Adolescents)
Divalproex sodium (500-1500 mg/day) and sodium valproate (800-1500 mg/day) have good evidence for efficacy but carry significant risks. 2, 3
Strictly avoid valproate in adolescent females of childbearing potential due to teratogenic risk, including neural tube defects. 2, 3
Adverse events include weight gain, hair loss, tremor, and teratogenic potential. 2
Topiramate is another anticonvulsant option with evidence for migraine prevention. 3
NSAIDs for Prevention
- Naproxen or naproxen sodium shows modest effect on headache prevention in meta-analysis of placebo-controlled trials. 2
Treatment Principles
Start preventive medications at a low dose and titrate slowly. 3
Allow 2-3 months for full therapeutic effect before declaring treatment failure. 3
The goal is to reduce attack frequency by ≥50%, minimize disability, and restore responsiveness to acute treatments. 5, 6
Critical Pitfalls to Avoid
Do not allow frequent use of acute medications in response to treatment failure, as this creates a vicious cycle of medication-overuse headache. 1, 4
Do not prescribe opioids or butalbital compounds as rescue medications, even when other treatments fail initially. 1, 4
Do not delay preventive therapy while trialing multiple acute strategies when the teenager has frequent attacks. 4
Do not use valproate in adolescent females without explicit discussion of teratogenic risk and reliable contraception. 2, 3
Do not abandon triptan therapy after a single failed attempt—try a different triptan or different route of administration. 1
When to Refer to Neurology or Headache Specialist
Failure of two or more preventive medication classes after adequate trials (2-3 months each). 4
Presence of atypical features, hemiplegic migraine, or prolonged aura. 2
Development of chronic migraine (≥15 headache days per month). 4
Need for advanced therapies such as CGRP monoclonal antibodies or onabotulinumtoxinA. 1