Managing Increased Migraine Headaches After Medication Changes in a 78-Year-Old Patient
The addition of Jardiance (empagliflozin) is likely contributing to the increased migraine headaches, and should be discontinued while restoring the previous metformin dosage of 1000mg daily.
Assessment of the Current Situation
The 78-year-old patient was previously stable on:
- Trulicity (dulaglutide) - GLP-1 receptor agonist for diabetes
- Metformin 1000mg - First-line diabetes medication
- Emgality (galcanezumab) - CGRP monoclonal antibody for migraine prevention
Recent medication changes included:
- Addition of Jardiance (empagliflozin) - SGLT2 inhibitor
- Reduction of metformin from 1000mg to 500mg
These changes coincided with an increase in migraine headaches that were previously well-controlled.
Mechanism of Increased Headaches
Several factors may explain the increase in headaches:
Jardiance (empagliflozin) side effects: The FDA label for Jardiance warns about hypotension, which can trigger headaches 1. SGLT2 inhibitors can cause volume depletion and electrolyte disturbances that may precipitate migraines.
Reduced metformin dosage: The decrease from 1000mg to 500mg may have affected glycemic control. Fluctuations in blood glucose are known migraine triggers.
Recommended Management Approach
Step 1: Medication Adjustments
- Discontinue Jardiance (empagliflozin)
- Restore metformin to the previous effective dose of 1000mg daily
- Continue Emgality (galcanezumab) for migraine prevention
- Continue Trulicity (dulaglutide) for diabetes management
Step 2: Monitor Response
- Assess migraine frequency and severity over the next 2-4 weeks
- Monitor blood glucose levels to ensure adequate diabetes control
Step 3: If Headaches Persist
- Consider evaluation for other potential migraine triggers
- Assess if Emgality (galcanezumab) dosage needs adjustment
Rationale for Recommendation
Prioritizing quality of life: Migraine control is essential for maintaining quality of life in older adults. The American Academy of Neurology recommends prioritizing treatments that minimize side effects in elderly patients 2.
Diabetes management in older adults: According to the American Diabetes Association's Standards of Care for Older Adults (2024), glycemic targets should be less restrictive in older patients (HbA1c target of 8-9% may be appropriate) 3. This allows for simplification of diabetes regimens to improve quality of life.
Effectiveness of current migraine prevention: Galcanezumab (Emgality) has demonstrated significant efficacy in reducing monthly migraine days, with studies showing up to 50% reduction in migraine frequency 4, 5. Some patients even achieve 100% response (complete elimination of migraines) 6.
Safety of metformin: Metformin remains the first-line agent for older adults with type 2 diabetes and can be safely used in individuals with estimated glomerular filtration rate ≥30 mL/min/1.73 m² 3.
Important Considerations
Age-appropriate diabetes management: In a 78-year-old, the primary goal should be to prevent hypoglycemia and maintain quality of life rather than achieving tight glycemic control 3.
Medication burden: Simplifying medication regimens is recommended for older adults with multimorbidity 3. Removing Jardiance reduces pill burden and potential side effects.
Monitoring: Regular follow-up is essential to ensure both migraine control and diabetes management remain adequate after medication adjustments.
Common Pitfalls to Avoid
Adding more medications: Rather than adding another medication to treat the headaches, addressing the root cause (medication change) is preferable.
Ignoring temporal relationship: The clear temporal relationship between medication changes and symptom worsening strongly suggests causality.
Pursuing overly aggressive diabetes control: In older adults, the risks of tight glycemic control (including falls, cognitive impairment) often outweigh benefits.
Discontinuing effective treatments: Emgality should be continued as it was previously effective for migraine prevention.
By reverting to the previous medication regimen that provided good control of both diabetes and migraines, the patient's quality of life can be improved while maintaining adequate management of both conditions.