Treating Migraine in Teenagers

• What is the approach to management of the adolescent with migraine?

Approach to management of migraine in adolescents should be multifactorial, with attention to an aggressive acute treatment regimen, preventive medications when indicated, and biobehavioral management.

Acute Treatment

General Approach

In counseling patients with migraine, and in particular adolescents, it should be stressed that achieving a normal level of functioning as soon as possible is the goal of therapy. Common missteps in treatment include failure to take acute medication early into the headache, incorrect dosing, incompletely treating the headache, and avoidance of participating in daily activities when headaches occur.

Adolescent patients may frequently wait to take an acute medication, typically due participation in another activity, not having medication with them, or discomfort with taking medication in front of peers or at school. Additionally, patients who have headaches beginning in early childhood, with pronounced gastrointestinal (GI) features, may be aware that their headaches resolve after vomiting, and therefore get used to not treating with medications. When these patients reach adolescence, when GI symptoms tend to become less pronounced, they will need to be educated that taking medication early is imperative. Acute medications are typically more effective when taken earlier in the course of a migraine, and the importance of pausing to take medication at the onset of the headache should be stressed to all patients and parents. With that in mind, however, care should be taken to counsel patients regarding the potential for development of medication overuse headache. When headaches are frequent, a more detailed and intricate plan may need to be devised so that adolescents and parents know which headaches to treat with medication.

Given that first-line medications for treatment of migraines are over-the-counter, underdosing occurs commonly, as dosing listed on packaging is typically age-based, not weight-based. At initial visits, young adolescent patients will frequently report that a particular medication is not effective, but this is often because they are still receiving low/less optimal dosing. Clinicians should remember to follow weights and recommend dosing changes at the initial visit and follow-up visits as well.

Treatment goals, ie, complete resolution of pain and migrainous features with ability to return to normal functioning, should be made clear to patients and families at the onset of treatment. Patients frequently fall into a pattern of continuing to treat with a medication that may lessen but not completely ablate the pain of a headache, and then sleep and avoid activity. Upon awakening, the headache may be gone, however, given incomplete initial treatment, the headache may be more likely to recur within 24 hours. At that point, the headache may be more difficult to treat and therefore cause further decrease in functioning. If this cycle perpetuates, disability can become extremely burdensome in adolescents, significantly affecting school and social functioning. Therefore, a detailed plan for initial steps in management as well as steps to take should initial therapy fail to fully break the headache should be given to every patient.

Of note, given that dehydration is now recognized as a common trigger for migraine [8,9], it is generally our recommendation to drink 16 to 32 oz (depending on weight) of a hydrating fluid together with whichever acute medication is chosen, as rehydration likely assists in breaking migraines as well [8].