Diagnosing and Treating Migraine in Teens

Reviewed by Brian M. Plato, D.O., FAHS, neurologist and headache specialist at Norton Neuroscience Institute.

Migraine is a common, disabling condition among teenagers, making it difficult for them to keep up with school activities and their family and social lives, according to Brian M. Plato, D.O., FAHS, a neurologist and headache specialist at Norton Neuroscience Institute.

Migraine can have a significant impact on their quality of life. Teens with migraine often feel isolated, because they frequently have to break plans or miss school, and their quality-of-life scores can be on par with patients dealing with cancer.

Diagnosing childhood migraine without aura

Migraine is a clinical diagnosis, with headache and non-headache features.

Childhood migraine without aura requires two of the following headache features:

• Bilateral or frontal temporal headache
• Throbbing or pulsatile pain
• Moderate or severe intensity
• Aggravation from routine physical activity

A migraine diagnosis also requires one of the following non-headache features:

• Nausea and/or vomiting
• Light or sound sensitivity

For a pediatric migraine diagnosis, the attacks need to last at least two hours, compared with adult migraine, which has to be four hours.

Diagnosing the type of migraine means assessing the total number of headaches per month, according to Dr. Plato. Chronic migraine is 15 or more days per month; episodic migraine is fewer than 15 days per month.

Migraine in teens affects more females than males. As many as 1 in 5 females may experience migraine before age 20.

Among adolescents with migraine, only 22% have aura. Vomiting is also not prevalent, but many will have nausea, pulsating pain, light or sound sensitivity, and symptoms aggravated by physical activity.

Treating teens with migraine

The first tier for treating teens with migraine is lifestyle adjustments, according to Dr. Plato.

“I can’t believe how many kids wake up, hit the door, they’re on the bus. They haven’t had anything to eat for breakfast. They haven’t had a sip of water, and then there’s nothing until lunchtime,” Dr. Plato said.

Making sure teens get a decent amount of sleep and regular exercise, have limits on their screen time, and can manage their stress are all important. They also should minimize their caffeine, drink plenty of water and eat regularly throughout the day without skipping meals, according to Dr. Plato.

When lifestyle modifications are not effective, it may be necessary to prescribe preventive medications, which can include amitriptyline or topiramate. For patients and families who want to avoid prescription medications, there may be a role for over-the-counter supplements.

Dr. Plato most commonly recommends magnesium to his patients, about 500 milligrams a day, and often Coenzyme Q10, 200 milligrams twice a day.

For acute treatment, the pharmacological options are analgesics, anti-nausea medications and triptans, which are serotonin agonists.

Triptans are the mainstay of acute migraine treatment, and combining them with nonsteroidal anti-inflammatory drugs (NSAIDs) increases their effectiveness, especially if they’re taken early in the attack, according to Dr. Plato.

The effectiveness of a second dose tends to go down. If the first dose is ineffective, a patient should be encouraged to take something else.

“We want to minimize the amount that we’re using these to 10 or fewer days per month to avoid the development of medication overuse headache, or rebound headache,” Dr. Plato said.

Triptans should be prescribed in maximal doses to ensure their effectiveness, even if this means the patient experiences some side effects, according to Dr. Plato. The occasional side effects of triptans are nausea, especially if given by injection, and a tingling, rising sensation in the chest, which is usually an esophageal spasm.

Contraindications are a history of vascular disease or uncontrolled hypertension, a brainstem aura (formerly called a basilar migraine), a hemiplegic migraine, or an aura lasting more than 24 hours.

There is also a new class of migraine medication called gepants, which blocks a neuropeptide, CGRP, that is involved in the process of nerve propagation during migraine. The drugs in this class are ubrogepant (Ubrelvy) and rimegepant (Nurtec).

They can be used for migraine attacks or preventively and have few side effects, but they are very expensive — and because they are not indicated for patients under 18, may not be covered by insurance, according to Dr. Plato.