P MIGRAINE

 A

This 13-year-old girl is presenting with typical migraine features: headache with phonophobia (sensitivity to sound), photophobia (sensitivity to light), and a moderate headache that lasts for several hours. There are no red flags such as vision loss, nausea, vomiting, sensory symptoms, or weakness, which is reassuring and suggests that the headaches are likely primary and not secondary to a more serious condition.

The patient is having migraines once or twice a week, which is frequent and affecting her daily life, with 2 missed school days in the past month. Her migraines are not relieved by acetaminophen, but sleep helps.

Treatment Approach:

• Acute migraine treatment generally includes NSAIDs (e.g., ibuprofen or naproxen), which are effective for many patients, especially when used early in the course of the headache. NSAIDs work by reducing the inflammatory response associated with the migraine.

• Preventive treatment is considered when migraines are frequent (more than 4 headaches per month) and significantly affect quality of life. Since this girl is having migraines once or twice a week, it is reasonable to start her on preventive treatment if the current approach (NSAIDs and lifestyle modifications) does not suffice.

In addition to NSAIDs, other medications for acute treatment may include triptans (e.g., sumatriptan) if symptoms are not adequately managed with NSAIDs alone.

Non-pharmacological treatments like maintaining a consistent sleep schedule, avoiding known triggers (such as certain foods, dehydration, or stress), and ensuring regular physical activity can also be helpful in managing her migraines.

Differential Diagnosis Considerations:

• Tension-type headache: The patient’s symptoms (mild/moderate headache with phonophobia and photophobia) make this less likely because tension-type headaches are generally not associated with such symptoms.

• Cluster headaches: These are typically characterized by severe, unilateral periorbital pain with autonomic features such as tearing and nasal congestion, which this patient does not have.

• Sinus headache: While this can present with facial pain and pressure, it does not typically involve phonophobia or photophobia.

Conclusion: The most appropriate approach for this patient is to begin NSAIDs for acute migraine relief, and if these headaches continue to be frequent and disabling, preventive treatment should be considered (e.g., beta-blockers, topiramate, or amitriptyline).