Certainly. Below is a structured, comprehensive treatment plan for a 13-year-old male presenting with headache, based on the limited information provided and in the absence of red flag symptoms or abnormal findings.

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## 1. Primary Diagnosis

**Most Likely:**  
- **Primary Headache Disorder** (Migraine or Tension-Type Headache)

**Rationale:**  
- Headache is common in adolescents; primary headache disorders (migraine, tension-type) are most frequent in this age group.
- No red flag symptoms or abnormal findings reported.
- No evidence of secondary causes based on available data.

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## 2. Treatment Goals

- Relieve acute headache symptoms
- Minimize headache frequency and severity
- Prevent recurrence
- Identify and address potential triggers
- Monitor for and promptly identify secondary causes or complications

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## 3. Medication Recommendations

**A. Acute Symptomatic Relief**

- **First-line:**  
  - **Acetaminophen**: 10–15 mg/kg/dose orally every 4–6 hours as needed (maximum 75 mg/kg/day or 3,000 mg/day, whichever is lower)
  - **OR**  
  - **Ibuprofen**: 10 mg/kg/dose orally every 6–8 hours as needed (maximum 40 mg/kg/day or 2,400 mg/day, whichever is lower)

- **If migraine suspected and above ineffective:**  
  - **Consider triptans** (e.g., sumatriptan nasal spray 5–20 mg, as per age/weight, single dose; may repeat once in 2 hours if needed; max 40 mg/24h).  
  - *Note: Use only if migraine diagnosis is clear and under supervision of a healthcare provider.*

**B. Preventive Therapy:**  
- Not indicated unless headaches are frequent, severe, or disabling. Consider after specialist evaluation.

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## 4. Non-Pharmacological Interventions

- **Lifestyle Modifications:**
  - Ensure regular sleep schedule
  - Maintain adequate hydration
  - Encourage regular meals, avoid skipping meals
  - Limit caffeine and avoid known dietary triggers
  - Encourage regular physical activity
- **Headache Diary:**  
  - Record frequency, duration, intensity, triggers, and response to treatment
- **Stress Management:**  
  - Relaxation techniques, cognitive-behavioral therapy if stress is a trigger
- **Screen for Vision Problems:**  
  - Recommend eye exam if visual symptoms or if not recently performed

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## 5. Follow-Up Schedule

- **Initial follow-up:**  
  - 1–2 weeks after initial visit (sooner if symptoms worsen or red flags develop)
- **Ongoing:**  
  - Every 1–3 months if headaches persist or escalate, or as directed by clinical course

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## 6. Monitoring Parameters

- Headache frequency, duration, and severity (via diary)
- Response to medications (effectiveness, side effects)
- Emergence of red flag symptoms (see below)
- Impact on school attendance and daily activities
- Medication use (to avoid overuse/rebound headache)

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## 7. Patient Education Points

- Most headaches in adolescents are benign and self-limited
- Importance of regular routines (sleep, meals, hydration)
- Avoid overuse of pain medications (no more than 2–3 days per week)
- Identify and avoid headache triggers
- When to seek urgent care (see red flags below)
- Keep a headache diary for better management

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## 8. Potential Complications to Watch For

- Medication overuse headache (from frequent analgesic use)
- Progression to chronic daily headache
- Underlying secondary cause (e.g., infection, mass lesion) if new symptoms develop
- Impact on school performance or psychosocial functioning

**Red Flags Requiring Immediate Medical Attention:**
- Sudden, severe (“worst ever”) headache
- Headache with fever, neck stiffness, photophobia
- Confusion, altered mental status, seizures
- Focal neurological deficits
- Headache worsening over time or waking from sleep
- Recent significant head trauma

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## 9. Confidence Level

**Medium**

- Confidence is moderate due to limited clinical information and lack of detailed history or examination findings.
- Plan is appropriate for initial management of presumed primary headache in an adolescent, but further evaluation is warranted if symptoms persist, worsen, or new findings emerge.

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**Note:**  
This plan is based on available information and standard guidelines for pediatric headache management. A thorough clinical assessment is essential. Please consult a pediatrician or neurologist for further evaluation and individualized care.