What is the appropriate acute and preventive treatment for migraine in a 17-year-old male?

Treatment for Migraine in a 17-Year-Old Male

For acute treatment, start with ibuprofen 400–800 mg or naproxen 500–825 mg at headache onset; if NSAIDs fail after 2–3 episodes, escalate to a triptan (sumatriptan 50–100 mg, rizatriptan 10 mg, or zolmitriptan 2.5–5 mg). 1, 2, 3

Acute Treatment Algorithm

First-Line: NSAIDs for Mild-to-Moderate Attacks

• Ibuprofen 400–800 mg or naproxen sodium 500–825 mg should be taken as early as possible when pain is still mild, as early treatment dramatically improves efficacy 1, 2
• Aspirin 1000 mg is an alternative with strong evidence, though less commonly used in adolescents 1, 2
• Acetaminophen alone is ineffective for migraine and should not be used as monotherapy 1
• The combination of acetaminophen 1000 mg + aspirin 500–1000 mg + caffeine 130 mg is effective for mild-to-moderate attacks 1, 2

Second-Line: Triptans for Moderate-to-Severe Attacks

• If NSAIDs fail after 2–3 headache episodes, switch to a triptan 1, 2, 3
• Sumatriptan 50–100 mg is the most studied and cost-effective triptan 1, 2, 3
• Rizatriptan 10 mg reaches peak concentration fastest (60–90 minutes) among oral triptans 2, 3
• Zolmitriptan 2.5–5 mg is equally effective with good tolerability 1, 2
• Failure of one triptan does not predict failure of others—try at least 2–3 different triptans before abandoning this class 2, 3

Managing Nausea

• Add metoclopramide 10 mg orally 20–30 minutes before the analgesic if nausea is present, as it provides both antiemetic effects and synergistic analgesia 1, 2, 4
• Alternatively, prochlorperazine 10 mg orally is equally effective 1, 2

Critical Frequency Limitation

• Limit all acute medications to ≤2 days per week (≤10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 1, 2, 3

When to Initiate Preventive Therapy

Start preventive therapy if the patient has ≥2 migraine attacks per month causing disability lasting ≥3 days, or if acute medication is needed more than twice weekly. 1, 2

First-Line Preventive Options for Adolescents

• Propranolol 80–240 mg/day (divided doses) has the strongest evidence and is FDA-approved for migraine prevention 1, 2
• Topiramate (starting 25 mg/day, titrating to 50–100 mg/day) is effective but may cause cognitive side effects and weight loss 2, 5
• Amitriptyline 30–150 mg/day (starting 10–25 mg at bedtime) is preferred when comorbid depression, anxiety, or sleep disturbance exists 2

Contraindications to Avoid

• Never prescribe opioids (codeine, hydromorphone, oxycodone) or butalbital-containing compounds for migraine in adolescents—they provide questionable efficacy, cause medication-overuse headache, lead to dependency, and worsen long-term outcomes 1, 2, 3
• Triptans are contraindicated only if the patient has uncontrolled hypertension, ischemic heart disease, or cerebrovascular disease (extremely rare in a 17-year-old) 1, 2, 3

Lifestyle Modifications

Evidence-Based Non-Pharmacologic Strategies

• Maintain regular sleep schedule (consistent bedtime/wake time, 7–9 hours nightly)—sleep deprivation and irregular sleep are potent migraine triggers 6, 7
• Avoid skipping meals and maintain regular meal times—fasting triggers attacks 1, 8, 7
• Stay well-hydrated (adequate daily water intake)—dehydration is a common trigger 6, 7
• Regular aerobic exercise ≥3 times weekly reduces attack frequency, though this is the least-followed recommendation 6, 7
• Limit caffeine intake to consistent daily amounts (avoid both excessive intake and sudden withdrawal) 8, 6, 7
• Identify and manage stress through relaxation techniques or biofeedback 1, 6, 7

Dietary Considerations

• A headache diary tracking food intake, sleep, stress, and headache patterns helps identify individual triggers 1, 6, 7
• Common dietary triggers include aged cheese, chocolate, citrus fruits, processed meats (nitrites), monosodium glutamate, and aspartame 8, 7
• Avoid universal elimination diets—only eliminate foods clearly identified as personal triggers through diary tracking 8, 7
• Alcohol avoidance is critical in adolescents, as underage drinking is a significant cause of recurrent headache 8

Red Flags Requiring Urgent Evaluation

Neuroimaging (MRI preferred) is indicated if any of the following are present: 1, 2

• Thunderclap (sudden, severe) headache onset
• Progressive worsening of headache pattern
• New neurological deficits or atypical aura
• Headache awakening patient from sleep or worsened by Valsalva maneuver
• Recent head trauma
• Fever with headache
• Altered consciousness or memory impairment

Common Pitfalls to Avoid

• Do not prescribe acetaminophen alone—it is ineffective for migraine 1
• Do not allow frequent acute medication use (>2 days/week)—this creates medication-overuse headache and guarantees treatment failure 1, 2, 3
• Do not delay preventive therapy if the patient requires acute treatment more than twice weekly—this perpetuates the cycle of frequent attacks 1, 2
• Do not abandon triptans after one failure—try different triptans or different routes (nasal spray, subcutaneous) before concluding the class is ineffective 2, 3
• Do not order routine neuroimaging for typical recurrent migraine without red flags—this exposes the patient to unnecessary radiation and cost 1, 2