Treating Migraine in Teenagers

From the Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

Abstract

• Objective: To review the management of migraine in adolescent patients.
• Methods: Literature review in the context of 2 clinical cases.
• Results: Migraine is common in adolescents and can affect school and social functioning. Management options include lifestyle modifications and acute and preventative therapies. First-line medications for migraine in the adolescent population are over-the-counter medications, including ibuprofen, acetaminophen, and naproxen. Studies of efficacy of triptans in the treatment of pediatric migraine have been limited and results conflicting, largely due to high placebo response rates. Several classes of medications are commonly used for migraine prevention, including antidepressants and antiepileptics. Currently, topiramate is the only medication approved for prevention of migraine in patients 12 years and older. Biobehavioral treatments such as relaxation training, biofeedback, and cognitive behavioral therapy have been evaluated in randomized controlled trials and found to be efficacious.
• Conclusion: 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.

Case Study 1

Initial Presentation

A 13-year-old left-handed boy with allergic rhinitis has been referred by his pediatrician for evaluation of headaches.

History

The headaches have been occurring since he was 7 years old. He describes a bilateral frontal and periorbital pain, which is either aching or throbbing in nature. There is associated photophobia and phonophobia, and the pain worsens with activity. When he was younger the headaches were frequently associated with emesis. He occasionally gets tenderness of his face during the headaches, mostly in the areas adjacent to his nose and above his eyes and occasionally associated rhinorrhea.

Initially the headaches were mild and occurring infrequently, but for the past 6 months they have been more severe and occurring 1 to 3 times per week, sometimes on consecutive days. They typically begin in the afternoon but at times occur soon after waking in the morning. If they do occur in the morning, they worsen after getting out of bed. He denies any type of warning symptoms indicating the headache will occur, and has no associated focal neurologic symptoms associated with the headaches. His mother tries to minimize medication intake so will typically wait to see if the headache is severe before giving him medication, typically 2 chewable children’s ibuprofen, which helps some of the time; however, his headache often does not completely abate unless he naps. He has also been taking loratadine daily due to concerns that his headaches may be secondary to chronic sinusitis.

He is a good student and enjoys school, but notes stress surrounding tests. He reports missing 4 days of school in the past 3 months as well as coming late twice. He thinks that there were 9 additional days in which he was unable to function at his full ability at school and at least 5 times he was unable to concentrate on his homework. He plays soccer 4 to 5 times per week. He says twice he had to skip soccer practice to due to headache and at least 3 other times he needed to take breaks during soccer due to headache. He is unsure how much he drinks on an average day but he drinks mostly with meals. He does not drink caffeine. He gets into bed at 10 pm and sometimes does not fall asleep until after 11 pm, often due to worry about tests. He often plays with his tablet when trying to fall asleep. He wakes up at 6 am for school. He typically eats 3 meals per day but occasionally misses breakfast if he is rushed in the morning.