What first‑line preventive migraine medications, including dosing and side‑effect considerations, are recommended for a 12‑to‑17‑year‑old adolescent with frequent migraines that interfere with school, sports, and social activities?

Preventive Migraine Medication for Teens

For a 12-to-17-year-old with frequent disabling migraines, discuss with the family that placebo was as effective as medications in many pediatric trials, then offer amitriptyline combined with cognitive behavioral therapy, topiramate, or propranolol as first-line preventive options. 1

When to Consider Preventive Treatment

• Initiate preventive therapy when migraines occur ≥2 days per month with adverse effects despite optimized acute treatment, or when headaches significantly interfere with school, sports, and social activities. 2, 3
• Consider prevention if there is medication overuse (≥15 days/month with NSAIDs or ≥10 days/month with triptans). 2
• Prevention is appropriate when acute medications fail, are contraindicated, or cause troublesome side effects. 4

Critical Counseling Point

Before starting any preventive medication, you must discuss with the patient and family that placebo was as effective as the studied medications in many pediatric trials. 1 This high placebo response rate in adolescents means that non-pharmacologic approaches and lifestyle modifications should be emphasized alongside any medication decision.

First-Line Preventive Medications

Amitriptyline Combined with Cognitive Behavioral Therapy

• Dosing: Start at 10 mg orally at bedtime, titrate up to 10-100 mg nightly based on response. 3
• Enhanced efficacy when combined with CBT compared to amitriptyline alone. 1, 3
• Contraindications: Age <6 years, heart failure, co-administration with MAO inhibitors or SSRIs, glaucoma. 3
• Side effects: Sedation, dry mouth, weight gain, constipation.
• Monitoring: Evaluate response at 2-3 months using headache calendars tracking frequency, severity, and disability. 3

Topiramate

• Dosing: Start low and titrate to 50-100 mg orally daily. 3
• Critical warning for adolescent females: Topiramate is teratogenic. 1, 3
  • Mandatory counseling: Advise effective birth control methods and folate supplementation for all females of childbearing potential. 1, 3
• Contraindications: Pregnancy, lactation, nephrolithiasis, glaucoma. 3
• Side effects: Cognitive slowing, paresthesias, weight loss, kidney stones, metabolic acidosis.
• Monitoring: Evaluate at 2-3 months; define success as ≥50% reduction in attack frequency. 3

Propranolol

• Dosing: 80-160 mg orally daily in long-acting formulations. 3
• Appropriate for patients with comorbid hypertension or anxiety. 3
• Contraindications: Asthma, cardiac failure, Raynaud disease, atrioventricular block, depression. 3
• Side effects: Fatigue, bradycardia, hypotension, exercise intolerance (important consideration for athletic teens).
• Evidence: One of the few agents with documented efficacy in systematic pediatric studies. 5

Choosing Between First-Line Options

Select based on the adolescent's specific profile:

• Athletic teens or those with depression: Avoid propranolol; consider amitriptyline + CBT or topiramate. 3
• Teens with comorbid anxiety or hypertension: Propranolol is ideal. 3
• Overweight teens: Topiramate may offer weight loss benefit; avoid amitriptyline which causes weight gain. 3
• Females of childbearing potential: If choosing topiramate, ensure contraception counseling and folate; otherwise, prefer amitriptyline + CBT or propranolol. 1, 3
• Teens with comorbid depression: Amitriptyline + CBT is appropriate. 3

If First Agent Fails

Try another first-line option rather than declaring treatment failure prematurely. 3 Give each medication an adequate 2-3 month trial at therapeutic doses before switching. 3, 4

Essential Non-Pharmacologic Foundation

Lifestyle modifications must be implemented regardless of medication choice:

• Regular sleep schedule: Consistent bedtimes and wake times, sufficient sleep duration. 2, 5
• Regular meal times: Avoid fasting or skipped meals. 2, 6
• Adequate hydration: Maintain consistent fluid intake throughout the day. 2
• Trigger identification and avoidance: Use headache diaries to identify specific triggers (certain foods, stress, bright lights, strong smells). 2, 6
• Stress management techniques: Relaxation techniques, biofeedback. 2, 7
• Cognitive behavioral therapy: Effective as monotherapy and enhances medication efficacy. 2, 7

Common Dietary Triggers to Discuss

Counsel on potential food triggers: cheese, chocolate, citrus fruits, hot dogs, monosodium glutamate, aspartame, fatty foods, ice cream, caffeine withdrawal. 6 However, avoid a universal elimination diet; instead, use a headache and diet diary to identify individual triggers. 6

Optimizing Acute Treatment First

Before adding preventive therapy, ensure acute treatment is optimized:

• First-line acute treatment: Ibuprofen 10 mg/kg at earliest onset of headache. 2, 3
• For adolescents with inadequate response to ibuprofen: Consider sumatriptan/naproxen oral combination, zolmitriptan nasal spray 5 mg, sumatriptan nasal spray, or rizatriptan ODT. 1, 2
• Counsel to treat early in the attack for maximum effectiveness. 1, 2

Special Contraception Consideration

Adolescent females with migraine with aura should not be prescribed combined hormonal contraceptives due to increased stroke risk. 3 This is critical when counseling about birth control for topiramate use.

Monitoring and Follow-Up

• Use headache calendars to objectively track attack frequency, severity, and disability. 3
• Define treatment success as ≥50% reduction in attack frequency. 3
• Re-evaluate therapy at 2-3 months after initiation or dose change. 3, 4
• Avoid medication overuse: Educate families that overuse of acute medications can worsen headaches. 1, 2, 3

When to Refer to Specialist

Refer to headache specialist if:

• Acute medication provides insufficient pain relief despite optimization. 3
• Diagnosis is uncertain or symptoms are atypical/concerning for secondary headache. 2
• Patient develops chronic migraine (≥15 headache days per month). 3
• Multiple preventive trials have failed. 3

Critical Pitfall to Avoid

Do not use divalproex/valproate in adolescent females of childbearing potential due to teratogenicity and lack of proven efficacy superior to other options. 1 The American Academy of Neurology guidelines specifically warn about teratogenic effects and recommend folate supplementation only for topiramate, not valproate. 1