Management of Migraines in Adolescents

Acute Treatment Options

The American Academy of Neurology recommends ibuprofen (10 mg/kg) as the first-line medication for treating migraine pain in children and adolescents 1, 2
Treatment should be administered early in the migraine attack for maximum effectiveness 1, 2
For mild attacks, bed rest alone might be sufficient in some cases 3
For adolescents who don't respond to NSAIDs, consider sumatriptan/naproxen oral combination, zolmitriptan nasal spray, sumatriptan nasal spray, or rizatriptan orally disintegrating tablets (ODT) 1, 4
For rapidly escalating headache pain, consider non-oral triptan formulations (nasal sprays) 1, 2
For attacks with significant nausea/vomiting, use non-oral triptan formulations or add an anti-emetic 1, 2
If one triptan is ineffective, try another triptan or an NSAID-triptan combination 1, 2

Consider preventive treatments when migraines occur frequently (≥2 days per month with adverse effects despite optimized acute treatment) or are disabling 1, 2, 5
Evidence-based options to consider include amitriptyline combined with cognitive behavioral therapy, topiramate, propranolol, beta-blockers (atenolol, bisoprolol, metoprolol), and candesartan 1, 5, 6
Discuss with patients/families that placebo was as effective as many studied medications in trials 1, 7

Educate patients and families about migraine triggers and avoidance strategies, regular sleep schedules, regular meal times, adequate hydration, and stress management techniques 1, 4
Consider non-pharmacological approaches such as relaxation techniques, cognitive behavioral therapy, and neuromodulatory devices (in select cases) 4, 5, 7

The clinical features of migraine in children/adolescents differ from adults, with attacks often being shorter (2-72 hours), headache being more often bilateral, and gastrointestinal disturbances being commonly prominent 3, 4
Management requires active help from family members and teachers, with education of both being necessary 3, 6
Avoid medication overuse, which can occur with frequent use of acute medications (≥15 days/month with NSAIDs or ≥10 days/month with triptans) 4, 6
Consider comorbidities (anxiety, depression, sleep disturbances) when selecting treatments 6
Refer to specialist care if acute medication provides insufficient pain relief, diagnosis is uncertain, or symptoms are atypical or concerning for secondary headache 3, 4

The American Academy of Neurology recommends starting with ibuprofen 10 mg/kg as first-line acute treatment for all pediatric migraine patients, administered at the earliest onset of headache 8
For mild attacks in younger children, bed rest alone may suffice before initiating pharmacotherapy, according to the International Headache Society 9

The American Headache Society recommends zolmitriptan nasal spray 5 mg as the evidence-based dose for adolescents 12-17 years, providing rapid and effective headache relief with a favorable safety profile 8
The American Academy of Neurology suggests considering zolmitriptan when NSAIDs have failed to provide adequate relief, or when the migraine presents with moderate to severe intensity, or when rapid escalation of headache pain occurs, or when significant nausea/vomiting is present 8

The American Heart Association advises against prescribing triptans, including zolmitriptan, to patients with cardiovascular disease, uncontrolled hypertension, or hemiplegic migraine, as recommended by the National Institute of Neurological Disorders and Stroke 9
The American Academy of Neurology recommends not using triptans more than 10 days per month to prevent medication overuse headache 8

The American Gastroenterological Association suggests adding an antiemetic, such as domperidone for ages 12-17 years, if nausea or vomiting is prominent, as recommended by the European Neurological Society 9