What is the appropriate acute and preventive management for a 16‑year‑old female with a known history of migraine presenting with an 8/10 headache, nausea, photophobia, and phonophobia?

Acute and Preventive Management of Migraine in a 16-Year-Old Female

For this 16-year-old presenting with severe migraine (8/10 pain with nausea, photophobia, and phonophobia), treat the acute attack immediately with a triptan—sumatriptan 50-100 mg orally is first-line for moderate-to-severe migraine in adolescents over 12 years old, providing headache response in 50-62% at 2 hours and 68-79% at 4 hours. 1, 2

Acute Treatment Strategy

First-Line Acute Therapy

• Administer sumatriptan 50 mg or 100 mg orally for this moderate-to-severe attack (pain 8/10 with disabling associated symptoms). 1
• The 50 mg and 100 mg doses show no statistically significant difference in efficacy, but both are superior to 25 mg and provide headache response (reduction to mild or no pain) in 50-62% of patients at 2 hours and 68-79% at 4 hours. 1
• Triptans are appropriate and effective in adolescents over 12 years old with moderate-to-severe migraine attacks. 2

Antiemetic Management

• Use domperidone rather than metoclopramide for nausea in this adolescent patient, as domperidone does not cross the blood-brain barrier and avoids extrapyramidal side effects that can occur with metoclopramide in young patients. 2

Alternative Acute Options

• NSAIDs alone may be considered for mild-to-moderate attacks, but given the severity (8/10 pain), this patient requires triptan therapy. 3
• Acetaminophen is not based on high-quality evidence and better options exist for migraine management. 2

Rescue Medication Guidelines

• A second dose of sumatriptan or other medication may be used 4-24 hours after initial treatment if headache recurs or does not respond adequately. 1
• No remedication should occur within 2 hours of the initial dose. 1

Preventive Treatment Considerations

When to Initiate Prevention

• Consider preventive therapy if this patient experiences ≥2 attacks per month that cause significant disability, which appears likely given the severity of this presentation. 4
• The American Academy of Neurology recommends topiramate as the only medication with proven efficacy in randomized controlled trials specifically for chronic migraine, starting at 25 mg at bedtime and titrating by 25 mg weekly to target dose 100 mg daily. 5

Medication-Overuse Prevention

• Limit acute medication use to <10 days per month to prevent medication-overuse headache. 5
• Maximum 2 days per week for triptan use and maximum 10 days per month for any acute medication. 5
• Implement a headache diary to track frequency and prevent medication overuse recurrence. 5

Diagnostic Confirmation

Clinical Features Present

• This patient meets International Headache Society criteria for migraine: unilateral location, throbbing character, moderate-to-severe intensity (8/10), with nausea, photophobia, and phonophobia. 6
• The presence of photophobia and phonophobia together with nausea are central diagnostic criteria for migraine. 6

Essential History Elements

• Document age at onset, duration of episodes, frequency, pain characteristics, accompanying symptoms, any aura symptoms, and history of acute medication use. 6
• Use a headache diary to record frequency, intensity, accompanying symptoms (nausea, photophobia, phonophobia), and medication use. 6

Red Flags to Exclude

• Fever with headache is NOT a feature of primary migraine and mandates investigation for secondary causes such as meningitis or encephalitis. 7
• Neck stiffness, altered consciousness, or focal neurological signs require urgent evaluation. 7

Special Considerations for Adolescent Females

Contraception Counseling (if applicable)

• If this patient requires contraception, progestin-only methods are safe and recommended (progestin-only pills, depot medroxyprogesterone acetate injection, etonogestrel implant, levonorgestrel IUD). 5
• Combined hormonal contraceptives are contraindicated in women with migraine who smoke or are >35 years old due to increased stroke risk. 5

Follow-Up Plan

Monitoring Response

• Assess headache response at 2 and 4 hours after triptan administration. 1
• Track the need for second doses or rescue medications over 24 hours. 1
• Maintain a headache calendar recording frequency of migraine, intensity, and acute medication use to guide preventive therapy decisions. 6, 5

Reassessment Triggers

• If attacks occur ≥2 times per month with significant disability, initiate preventive therapy. 4
• If acute medication use exceeds 10 days per month, address medication-overuse risk immediately. 5