Treating Migraine in Teenagers
How should the patient be treated?
Acute Treatment
The patient reports only minimal response to ibuprofen. However, he is only taking 200 mg and does not take it until well after the headache has started. He should be instructed to take ibuprofen 600 mg (~10 mg/kg) as soon as the headache starts, along with 32 oz of a sports drink, and told that he should repeat this dose in 4 hours if his headache has not completely resolved with the first dose. As his headaches are occurring less than 3 times per week on average, he can do this with every headache. He should be given a note for school allowing him to receive the medication at school, and noting the importance of allowing him to get the medication as soon as he reports a headache. Given that some of his headaches occur on consecutive days, we suspect some may be continuations of a prior headache, so again the importance of obtaining complete pain relief from his acute medication should be stressed. If at his next follow-up visit he reports not always having complete relief with ibuprofen, we would consider trying naproxen instead, and/or adding a triptan, most likely sumatriptan 100 mg given its availability. He would need to understand that he may only use the triptan for 4 to 6 headache days/month. Depending on his response to sumatriptan, it could be used alone or in combination with his NSAID. He also may be instructed to use an NSAID alone for more mild headaches and his NSAID together with sumatriptan for more severe headaches.
Preventive Treatment
PedMIDAS score is a 25, indicating mild disability, however his migraines are frequent, occurring 1–3 times per week and clearly having a significant impact on his functioning. We would therefore recommend starting a prophylactic medication. He notes difficulty remembering to take medications as well as difficulty falling asleep, so amitriptyline would be a good choice for him. For his weight of 50.9 kg, we would start with at 12.5 mg at night and increase by 12.5 mg every 2 weeks to a dose of 50 mg (~1mg/kg/day). He and Mom should be counseled that it will likely take at least a few weeks on his goal dose before they start to see results. He should be counseled also to report to Mom immediately if he has any depressive or suicidal thoughts. Topiramate is another option, especially as it is FDA-approved for migraine prevention in children older than 12 years, although twice daily dosing may be a factor in maintaining compliance. Careful discussion with the patient and family in regards to the potential risks and benefits is important prior to starting any preventative medication.
Biobehavioral Management
The patient should be drinking 8–10 cups of non-caffeinated fluid per day and additional cups on days he plays soccer. He should be given a school note to this effect so he may carry a water bottle at school. He eats well, but the importance of not skipping breakfast should be stressed, and ideas for fitting this in should be given. The importance of a consistent bedtime routine should be stressed, with good sleep hygiene to assist with easier sleep onset. It should be made clear that he should not be using screens within an hour prior to bed. He already exercises frequently and should be commended for being active. Given his report of frequent headaches which are impairing school attendance, functioning at school, and participation in soccer activities, screening for potential co-morbid psychiatric issues and making a referral for further treatment with a pediatric pain psychologist focused on coping with chronic pain is appropriate.
Case Study 2
Initial Presentation and History
A 16-year-old right-handed girl who has been having headaches since she was 10 years old presents for evaluation. She reports unilateral mostly right-sided headaches, which are throbbing and associated with photophobia, phonophobia, osmophobia, nausea, and occasionally vomiting. She has no premonitory or aura symptoms. Her headaches typically occur once a week but she has noted that they tend to be more frequent around the time of her menses and that often these headaches do not fully respond to naproxen, which typically works to break her migraines during other times in the month. Upon further review, she believes these headaches typically start on the day or two prior to her menses, and that this happens almost every month. She often misses school due to these headaches. Her mother would like to know whether the patient should see a gynecologist to potentially be placed on birth control to control her headaches.
Physical Examination
On examination, weight was 61.5 kg (75.8 percentile), height 157.1 cm (18.4 percentile), BMI 24.91 (84 percentile), blood pressure 112/55 mm Hg, and heart rate 90 bpm. Her general physical and neurologic exam results were normal. She had tightness over the left trapezius muscles, otherwise the remainder of headache examination was unremarkable.
What is the probable diagnosis?
According to the ICHD-IIIβ, the patient meets criteria for episodic migraine without aura. Based on the history, she likely also has menstrually related migraine without aura [5].Officially, however, 3 months of prospective documentation is needed to make this diagnosis. Menstrually related migraine is included in the appendix of the ICHD-IIIβ, meaning there is ongoing debate about how it should be classified. According to the current appendix criteria, headaches should meet criteria for migraine without aura and also have documented and prospectively recorded evidence over at least 3 consecutive cycles with headaches confirmed on day 1+/– 2 (ie, 2 days prior to onset of menstruation or within the first 3 days of menstruation) in at least 2 out of 3 menstrual cycles, with migraines occurring during other times of the month as well [5]. This is distinguished from pure menstrual migraine without aura, in which migraines occur only during days 1+/–2 of menstruation but not during other times of the month [5].While we therefore cannot say that the patient meets ICHD IIIβ criteria for menstrually related migraine due to the lack of prospective documentation, her history suggests this.
Menstrually Related Migraine
An association of migraine with menses is well described in adults, occurring in up to 60% of adult female migraine patients [81].In adults, it has been observed that the migraines associated with the menstrual cycle tend to be more severe [82],associated with more nausea and vomiting [82],longer and less responsive to acute medications [83],and associated with more work-related disability [83]. Recently, analysis of data from the American Migraine Prevalence and Prevention (AMPP) Study found that women with pure menstrual migraine and menstrually associated migraine have on average higher MIDAS scores than those with non-menstrual migraine [81].
Only one study has explored menstrually related migraines in adolescents [84].It was a clinic-based study that found a similar prevalence—50% of adolescent patients who had reached menarch noted an association of migraine with their menses. Overall worse disability was not demonstrated in this study, but individual menstrual attacks were not compared with nonmenstrual attacks [84].No other studies have addressed this population, but it is clear that the pattern of menstrually related migraine exists in adolescents and it is important to recognize this pattern as these patients may require additional focused care in addition to standard migraine management.
What are treatment options?
In adults, options for more specific management of pure menstrual migraine and menstrually related migraine include intermittent prophylaxis with NSAIDs or triptans or use of hormonal contraceptives. There are no studies addressing any of these treatments in adolescents, so at this point management decisions must be based on evidence extrapolated from adult studies as well as attention to specific concerns in adolescent patients.
Generally, intermittent prophylaxis (using a medication a few days prior to and during the first few days of menses) with various medications has shown efficacy in adult studies. This approach may be more appropriate for patients with pure menstrual migraine, as there is less likelihood of precipitating medication overuse in this population. It can be considered in patients with menstrually related migraine as well if typical daily preventives have not been effective. One small open-label trial using naproxen 550 mg daily prior to and during menses (at differing schedules depending on the month) showed slightly decreased frequency and severity of headaches during that time [85].However, triptans are what are most commonly used.
Triptans
Frovatriptan is the longest-acting triptan and the one used most commonly for intermittent prophylaxis. One double-blind randomized controlled crossover study showed improvements in headache frequency, severity, and duration using frovatriptan 2.5 mg BID for 6 days total starting 2 days prior to menses [86].Frovatriptan 2.5 mg daily showed some efficacy as well but was not as effective as 2.5 mg BID [86].One prospective randomized placebo-controlled trial demonstrated more headache-free cycles using frovatriptan 2.5 mg BID for 6 days total starting 2 days prior to menses, as compared to placebo [87].
Naratriptan, also a longer-acting triptan, was studied in 3 prospective double-blind trials at doses of 1 mg BID used for 5 days total starting 2 days prior to menses, and all 3 showed a decrease in headache frequency as compared to placebo [88,89].Of note no efficacy was shown using 2.5 mg daily [88].
