How should I evaluate and manage a 16‑year‑old adolescent with episodic migraine, including criteria for diagnosis, red‑flag exclusion, lifestyle modifications, acute pharmacologic therapy, and indications for preventive medication?

Evaluation and Management of a 16-Year-Old with Episodic Migraine

For a 16-year-old adolescent with episodic migraine, ibuprofen 400–800 mg is the first-line acute treatment, and preventive therapy with propranolol should be initiated if attacks occur ≥2 days per month with significant disability or if acute medication is needed more than twice weekly. 1

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Diagnostic Criteria and Red-Flag Exclusion

Establishing the Diagnosis

• Migraine in adolescents requires ≥5 attacks lasting 2–72 hours (shorter than the adult 4-hour minimum), with at least two of the following: unilateral or bilateral location, pulsating quality, moderate-to-severe intensity, or aggravation by routine activity. 1
• At least one accompanying symptom must be present: nausea/vomiting, photophobia, or phonophobia. 1
• Headache descriptions may be less reliable from adolescents than from parents, who should provide collateral history about attack frequency, duration, and functional impact. 1
• Attacks in adolescents are often shorter, more frequently bilateral, less often pulsating, and gastrointestinal symptoms (nausea, vomiting) are commonly prominent. 1

Red-Flag Assessment

• Rule out secondary headache by screening for thunderclap onset, progressive worsening, fever with neck stiffness, focal neurological deficits, atypical aura, recent head trauma, or new-onset headache after age 50. 2
• Neuroimaging (MRI preferred) is indicated only when red-flag features are present; routine imaging for typical recurrent migraine without red flags is discouraged to avoid unnecessary radiation, cost, and incidental findings. 3

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Acute Pharmacologic Therapy

First-Line Treatment

• Ibuprofen 400–800 mg (dosed by body weight) is the recommended first-line acute medication for children and adolescents with migraine. 1
• Ibuprofen should be taken early in the attack while pain is still mild to maximize effectiveness. 2
• Bed rest alone may suffice for attacks of short duration in younger children. 1

Second-Line Treatment for Adolescents (Age 12–17)

• If ibuprofen fails after 2–3 episodes, escalate to a triptan: sumatriptan nasal spray 5–20 mg, zolmitriptan nasal spray, rizatriptan orally disintegrating tablet, or almotriptan oral are FDA-approved options for adolescents aged 12–17 years. 1
• Nasal spray formulations (sumatriptan, zolmitriptan) are the most effective triptan delivery routes in adolescents. 1
• If one triptan is ineffective, try a different triptan or a combination of NSAID plus triptan, as failure of one does not predict failure of others. 1

Adjunctive Therapy for Nausea

• Domperidone can be used for nausea in adolescents aged 12–17 years, although oral administration is unlikely to prevent vomiting. 1
• For rapid progression to peak intensity or significant vomiting, consider non-oral routes (nasal spray triptans). 1

Critical Frequency Limitation

• Limit all acute medications to ≤2 days per week (≤10 days per month) to prevent medication-overuse headache, which can paradoxically increase headache frequency and lead to daily headaches. 1

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Lifestyle Modifications and Trigger Management

Education and Behavioral Interventions

• Active involvement of family members and teachers is necessary for clinical management in children and young adolescents; education of both is essential. 1
• Advise patients and families to identify and avoid modifiable triggers, including sleep deprivation, stress, excessive caffeine intake, tobacco, and alcohol. 1
• A headache diary (paper or smartphone-based) should be maintained to track attack frequency, severity, duration, triggers, and acute medication use; this improves accuracy of reporting and helps identify patterns. 1, 2

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Indications for Preventive Medication

When to Initiate Prevention

• Preventive therapy is indicated if the adolescent experiences ≥2 migraine attacks per month producing disability lasting ≥3 days, uses acute medication more than twice per week, has contraindication to or failure of acute treatments, or has uncommon migraine conditions (hemiplegic migraine, prolonged aura, migrainous infarction). 1, 4
• Patient and family preference for prevention, adverse events with acute therapies, and cost considerations are additional factors supporting initiation. 1

First-Line Preventive Options

• Propranolol 80–240 mg/day (started at 40 mg twice daily, titrated gradually) is the first-line preventive medication for adolescents, with strong evidence from multiple randomized controlled trials and an excellent safety profile. 1, 4
• Topiramate 50–100 mg/day (started at 25 mg at bedtime, increased by 25 mg weekly) is an alternative first-line option, but is absolutely contraindicated if pregnancy is possible due to teratogenic risk (neural tube defects); effective contraception and folate supplementation are mandatory if prescribed to adolescent females. 1, 4
• Timolol 20–30 mg/day may be considered as an alternative beta-blocker with similar efficacy and safety to propranolol. 1, 4

Second-Line Preventive Options

• Amitriptyline 30–150 mg/day combined with cognitive behavioral therapy is a second-line option, particularly when comorbid depression, anxiety, or sleep disturbances are present. 1
• Amitriptyline alone (without cognitive behavioral therapy) has limited evidence for efficacy in pediatric migraine prevention. 1
• Divalproex sodium or sodium valproate must be strictly avoided in females of childbearing potential due to teratogenic risk. 1

Evidence Limitations and Shared Decision-Making

• The evidence base for preventive medications in children and adolescents is confounded by a high placebo response in clinical trials, resulting in low therapeutic gain. 1
• Discuss with patients and families whether to use a preventive medication, since placebo was as effective as the studied medication in many trials; shared decision-making is essential. 1
• Efficacy of preventive therapy should be assessed after 2–3 months for oral agents. 1

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Referral to Specialist Care

• Referral to a pediatric neurologist or headache specialist is indicated if acute medication provides insufficient pain relief despite optimization, if preventive therapy fails after adequate trials, or if the diagnosis is uncertain. 1
• Specialist referral is also appropriate for chronic migraine (≥15 headache days per month for >3 months) or medication-overuse headache. 1

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Common Pitfalls to Avoid

• Do not prescribe opioids or butalbital-containing compounds for adolescent migraine; they have questionable efficacy, lead to dependency, cause rebound headaches, and result in loss of efficacy over time. 1, 3
• Do not allow patients to increase frequency of acute medication use in response to treatment failure; this creates a vicious cycle of medication-overuse headache. Instead, transition to preventive therapy while optimizing acute treatment strategy. 3
• Do not abandon triptan therapy after a single failed attempt; if one triptan is ineffective, try a different triptan, as failure of one does not predict failure of others. 1
• Do not prescribe topiramate or valproate to adolescent females without contraception counseling and folate supplementation, due to the high risk of neural tube defects and other fetal harm. 1, 4