Treating Migraine in Teenagers

• How should this patient be managed?

The patient is having frequent and disabling migraines, so starting a preventive medication would be appropriate. She has migraines throughout the month in addition to during her menses, so a daily prophylactic would be more appropriate than intermittent prophylaxis surrounding her menstrual cycle only. At this point, our recommendation would be to start a daily preventive with either amitriptyline or topiramate. Given that naproxen is not breaking some of her migraines, she should be given a prescription for a triptan. Sumatriptan 100 mg would be an appropriate first choice, and she can be instructed to use it along with her naproxen at the onset of her menstrual migraines. She can use it for other migraines as well but she should be instructed not to use it more than 4 to 6 times per month. She should keep a diary for the next 3 months noting most importantly headache days as well as days of menstruation, so that a more definitive pattern can be confirmed and an official diagnosis based on ICHD-IIIβ criteria can be made. If her migraines do not improve with daily preventives, at that point discussion regarding potential for intermittent prophylaxis or trial of extended cycle hormonal contraception may be considered, although with caution and discussion of risks and benefits.

Corresponding author: Hope O’Brien, MD, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave., MLC 2015 Cincinnati, OH 45229.

Financial disclosures: None.