What is the recommended abortive treatment for an acute migraine in a teenager (12‑18 years old)?

Abortive Migraine Treatment in Adolescents (12–18 Years)

For adolescents aged 12–17 years with acute migraine, ibuprofen (weight-appropriate dosing) is the recommended first-line treatment, and if this fails after 2–3 episodes, escalate to intranasal sumatriptan (5–20 mg) or zolmitriptan nasal spray, which have the strongest evidence for efficacy in this age group. 1

First-Line Treatment: NSAIDs

• Ibuprofen at a dose appropriate for body weight is the guideline-recommended first-line medication for acute migraine in children and adolescents. 1

• Ibuprofen has demonstrated effectiveness in adolescent migraine with a favorable safety profile and is well tolerated compared to placebo. 2, 3

• Acetaminophen is probably effective and can be considered as an alternative first-line option for adolescents who cannot tolerate NSAIDs. 2, 3

• The combination of acetaminophen, aspirin, and caffeine has strong evidence in adults but is not specifically studied as a first-line option in the adolescent population. 4

Second-Line Treatment: Triptans (Nasal Formulations Preferred)

• If ibuprofen fails after 2–3 migraine episodes, escalate to a triptan—specifically intranasal formulations, which have the strongest evidence in adolescents. 1

• Sumatriptan nasal spray (5–20 mg) and zolmitriptan nasal spray are the most effective triptan formulations for adolescents aged 12–17 years, with multiple studies demonstrating superiority over placebo. 1, 2

• Oral sumatriptan combined with naproxen sodium has high-quality evidence in adolescents: all three doses tested (10/60 mg, 30/180 mg, and 85/500 mg) achieved significantly higher 2-hour pain-free rates (24–29%) compared to placebo (10%), with the 85/500 mg dose also providing sustained pain-free response from 2 to 24 hours. 5

• Rizatriptan and zolmitriptan oral formulations were safe and well tolerated in adolescents but did not demonstrate superiority to placebo in clinical trials, likely due to the high placebo response rate characteristic of pediatric migraine studies. 2, 3

• The apparent therapeutic gain for triptans in children and adolescents is low because of a confoundingly high placebo response in clinical trials, which explains why oral triptans have not consistently demonstrated benefit in younger patients. 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 can paradoxically increase headache frequency and lead to daily headaches. 4

• If an adolescent requires acute treatment more than twice weekly, initiate preventive therapy immediately rather than increasing the frequency of abortive medications. 4

Adjunctive Treatment for Nausea

• Domperidone can be used for nausea in adolescents aged 12–17 years, although oral administration is unlikely to prevent vomiting once it has started. 1

• Metoclopramide provides synergistic analgesia beyond its antiemetic effect and can be considered for adolescents with prominent nausea, though it should be limited to no more than twice weekly. 4

Route of Administration Considerations

• Non-oral routes (intranasal or subcutaneous) are preferred when significant nausea or vomiting is present early in the migraine attack, as oral medications may not be adequately absorbed. 4, 2

• Subcutaneous sumatriptan 6 mg provides the highest efficacy with onset within 15 minutes but has higher adverse event rates and is typically reserved for severe attacks in adolescents. 4

Treatment Timing

• Treat early in the attack while pain is still mild to maximize effectiveness—early treatment results in approximately 50% of patients becoming pain-free at 2 hours versus only 28% when treatment is delayed until pain is moderate or severe. 4, 2

Common Pitfalls to Avoid

• Do not abandon triptan therapy after a single failed attempt—if one triptan formulation is ineffective, try a different triptan or a different route of administration, as failure of one does not predict failure of others. 4

• Never prescribe opioids 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. 4

• Bed-rest alone may suffice in children with attacks of short duration, so pharmacologic treatment should be reserved for attacks that do not resolve with rest. 1

When to Refer to Specialist Care

• If acute medication provides insufficient pain relief despite optimized therapy (appropriate dose, early administration, trial of multiple agents), referral to specialist care is indicated. 1

• Adolescents requiring acute treatment more than twice weekly should be evaluated for preventive therapy, which may require specialist consultation if first-line preventives fail. 1, 4

Educational Components

• Clinical management in children and young adolescents usually requires active help from family members and teachers, so education of both is necessary. 1

• Counseling on lifestyle factors that can exacerbate migraine—including trigger avoidance, adequate sleep, regular meals, and hydration—is an essential component of management. 2

• Advise patients and families to keep a headache diary to track attack frequency, severity, medication use, and triggers, which helps identify patterns and prevent medication overuse. 4