How should I evaluate and manage a 16-year-old adolescent female presenting with recurrent headaches?

Evaluation and Management of Recurrent Headaches in a 16-Year-Old Female

Begin by systematically ruling out secondary causes using red-flag assessment, then establish whether this represents migraine, tension-type headache, or another primary headache disorder through detailed characterization of headache features and a headache diary. 1

Initial Red-Flag Assessment

Your first priority is to identify any features suggesting a life-threatening secondary headache that requires urgent neuroimaging or emergency referral:

Critical red flags requiring immediate action: 1, 2, 3

• Thunderclap headache ("worst headache of life")
• Altered consciousness, memory, or personality changes
• Focal neurological symptoms or signs on examination
• Papilledema with focal neurologic signs
• Neck stiffness with fever (meningitis)
• Recent head trauma with persistent headache
• Witnessed loss of consciousness

Concerning features warranting neuroimaging consideration: 1, 2, 3

• Headache awakening patient from sleep
• Progressive worsening over weeks to months
• Headache worsened by Valsalva, cough, or exertion
• New-onset headache (though less common in adolescents)
• Atypical aura lasting >60 minutes or with focal neurological symptoms
• Abnormal neurological examination findings

If the neurological examination is completely normal and no red flags are present, neuroimaging is NOT indicated, even for recurrent headaches. 1, 4 The yield of neuroimaging in pediatric patients with normal exams is extremely low (0.2%), equivalent to asymptomatic volunteers. 1

Detailed Headache Characterization

Once secondary causes are excluded, obtain specific details to differentiate primary headache types:

Essential history elements: 1, 5

• Duration of individual episodes: Migraine lasts 2-72 hours in adolescents (shorter than the adult 4-72 hour criterion), tension-type is variable (30 minutes to 7 days), cluster lasts 15-180 minutes 1, 2

• Frequency: Document headache days per month—if ≥15 days/month for >3 months with ≥8 days meeting migraine criteria, this is chronic migraine requiring different management 6, 1

• Pain location: Unilateral suggests migraine or cluster; bilateral suggests tension-type 1

• Pain quality: Pulsating/throbbing indicates migraine; pressing/tightening suggests tension-type; severe unilateral with autonomic features indicates cluster 1, 5

• Pain severity: Moderate-to-severe suggests migraine or cluster; mild-to-moderate suggests tension-type 1

• Aggravating factors: Routine physical activity worsens migraine but not tension-type 1

• Associated symptoms:

  • Nausea/vomiting PLUS photophobia AND phonophobia together = migraine 1, 5
  • Ipsilateral lacrimation, conjunctival injection, nasal congestion, ptosis = cluster headache 1
  • Absence of these features = tension-type headache 1

• Aura symptoms: Visual/sensory disturbances lasting 5-60 minutes, spreading gradually over ≥5 minutes, followed by headache within 60 minutes = migraine with aura 1, 2

• Family history: Strong family history of migraine significantly increases likelihood of migraine diagnosis 1, 5

• Menstrual relationship: Headaches linked to menstrual cycle suggest hormonal migraine 1

Critical pitfall: Many adolescents don't report milder headache days, only severe ones—ask directly: "Do you feel like you have a headache of some type on 15 or more days per month?" 6

Medication History Assessment

Document all current medication use carefully: 6, 1

• Over-the-counter analgesics (patients often don't consider these "real medications") 1
• Prescription acute treatments and their effectiveness
• Any preventive medications tried previously

Medication-overuse headache must be ruled out: If she takes non-opioid analgesics (ibuprofen, acetaminophen, aspirin) ≥15 days/month OR any other acute medication (triptans, combination analgesics) ≥10 days/month for >3 months, this represents medication-overuse headache requiring withdrawal and different management. 1

Headache Diary Implementation

Immediately initiate a headache diary before making definitive diagnosis. 6, 1 This is essential because:

• Adolescents have poor recall of headache frequency and characteristics
• Diary entries reduce recall bias and increase diagnostic accuracy
• If diary consistently fails to meet migraine criteria over multiple attacks, migraine is ruled out 1

Diary should document: 1

• Date and time of onset
• Duration of each episode
• Pain location, quality, and severity (0-10 scale)
• Accompanying symptoms (nausea, vomiting, photophobia, phonophobia)
• Triggers or precipitating factors
• Medications taken and their effectiveness

Diagnostic Criteria Application

For migraine without aura (most common in adolescents): 1, 2

• At least 5 lifetime attacks lasting 2-72 hours each
• At least 2 pain characteristics: unilateral, pulsating, moderate-to-severe intensity, OR aggravated by routine activity
• At least 1 associated feature: nausea/vomiting OR both photophobia AND phonophobia together

For tension-type headache: 1

• Bilateral location
• Pressing/tightening quality (not pulsating)
• Mild-to-moderate intensity
• NOT aggravated by routine physical activity
• Lacks nausea/vomiting AND lacks the combination of photophobia plus phonophobia

The presence of photophobia together with nausea strongly favors migraine over tension-type headache. 1

Acute Treatment Strategy

For mild-to-moderate attacks or first-line therapy: 6, 2

• Ibuprofen 400-800 mg every 6 hours (first-line) 2
• Alternative: Naproxen sodium 275-550 mg every 2-6 hours 6, 2
• Alternative: Aspirin 650-1,000 mg every 4-6 hours 6, 2

For moderate-to-severe attacks or when NSAIDs fail: 6

• Triptans (sumatriptan, rizatriptan, zolmitriptan, naratriptan) are migraine-specific and highly effective 6

For nausea/vomiting: 6, 2

• Ondansetron 8 mg sublingual/oral every 4-6 hours 2
• Metoclopramide or prochlorperazine as alternatives 6

Critical warning: Limit acute medication use to prevent medication-overuse headache. Avoid using acute treatments >10-15 days per month. 6, 1

Preventive Therapy Indications

Initiate preventive therapy if: 6, 2

• Headaches occur ≥2 days per month causing significant disability
• Quality of life is impaired despite optimized acute treatment
• Patient has chronic migraine (≥15 headache days/month for >3 months with ≥8 migraine days) 6, 1
• Frequent acute medication use risks medication-overuse headache 6

First-line preventive agents for adolescents: 2

• Propranolol (beta-blocker, first choice) 2
• Amitriptyline (tricyclic antidepressant, alternative) 2, 7
• Topiramate (anticonvulsant, alternative) 2

For tension-type headache: Amitriptyline is first-line preventive therapy if chronic (≥15 days/month). 1

Non-Pharmacological Management

Essential lifestyle interventions: 2

• Regular exercise: 40 minutes three times weekly can be as effective as some medications for prevention 2
• Maintain regular sleep schedule
• Identify and avoid triggers through diary review 2
• Consider relaxation training or behavioral therapy (well-accepted in adolescents) 7

Referral Criteria

Urgent neurology referral (within 48 hours): 1

• Any red-flag features present
• Patient unable to self-care even with help available
• Suspected spontaneous intracranial hypotension

Routine neurology referral (2-4 weeks): 1

• Diagnosis remains uncertain after diary review
• First-line treatments fail
• Chronic migraine requiring specialized preventive therapy 6

No referral needed: Typical primary headache with normal examination responding to first-line therapy. 1, 4

Common Pitfalls to Avoid

• Don't order neuroimaging for typical migraine with normal neurological examination—it adds cost without changing management and has extremely low yield. 1, 4

• Don't miss medication-overuse headache—specifically ask about ALL over-the-counter medication use, as adolescents often don't report this. 6, 1

• Don't use opioids (meperidine, butorphanol) for recurrent headaches—they cause dependency, rebound headaches, and loss of efficacy. 6

• Don't diagnose migraine without a headache diary—adolescent recall is unreliable, and diary documentation is essential for accurate diagnosis. 6, 1

• Don't overlook chronic migraine—if ≥15 headache days/month, this requires preventive therapy and has substantially greater burden than episodic migraine. 6, 1