Migraine Prevention and Treatment in Adolescents

Introduction to Migraine Management

The American College of Physicians recommends that topiramate should be used only after inadequate response or intolerance to β-blockers, valproate, venlafaxine, or amitriptyline, due to its higher frequency of adverse events compared to other preventive options, despite similar efficacy 4
Topiramate has documented teratogenic effects, and mandatory counseling about reliable contraception is required for adolescent females, along with folate supplementation and consideration of monthly pregnancy testing 1, 5

Ibuprofen should be the initial medication for treating individual migraine attacks in adolescents, dosed appropriately for body weight, with consideration of triptan options if ibuprofen fails 1, 2
Acute attacks should be treated early in the course of the headache for best results 1

Preventive medication is indicated for adolescents with two or more attacks per month producing disability lasting 3+ days per month, failure of or contraindication to acute treatments, or use of abortive medication more than twice per week 3
First-line preventive agents that should be tried before topiramate include propranolol, amitriptyline, and valproate/divalproex sodium, with dosages ranging from 80-240 mg/day for propranolol, 30-150 mg/day for amitriptyline, and 500-1500 mg/day for valproate/divalproex sodium 3, 4

Lifestyle modifications, including maintaining a regular sleep schedule, ensuring regular meals and adequate hydration, identifying and avoiding migraine triggers, and addressing acute medication overuse, are essential before or alongside any pharmacologic treatment 1, 6
Topiramate has common adverse effects, including paresthesias, cognitive impairment, fatigue, weight loss, metabolic acidosis, and increased kidney stone risk, and should be discontinued if inadequate response after 12 weeks, with a tapering protocol to minimize seizure risk 1, 5
Contraindications to avoid include history of kidney stones without careful consideration, untreated hyperthyroidism, and use with other medications that increase seizure risk 5