What is the best medication for a 91-year-old patient with migraines?

Best Medication for Migraine in a 91-Year-Old Patient

For a 91-year-old patient with migraines, non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, or naproxen sodium are the recommended first-line treatment, with careful monitoring due to age-related risks. 1, 2

Treatment Algorithm for Elderly Migraine Patients

First-Line Treatment

• NSAIDs (aspirin 650-1000 mg, ibuprofen 400-800 mg, or naproxen sodium) are recommended as first-line therapy for mild to moderate migraine attacks in elderly patients 1, 2
• Consider adding an antiemetic (such as metoclopramide) if nausea is present, which also improves gastric motility that may be impaired during migraine attacks 1, 2
• Use with caution in elderly patients due to increased risk of gastrointestinal bleeding and renal effects 1

Second-Line Treatment

• If NSAIDs are ineffective after three consecutive attacks, consider other options with careful cardiovascular risk assessment 1
• Triptans are generally not recommended as first-line therapy in elderly patients due to potential cardiovascular risks, though no robust evidence supports increased risk of cerebrovascular or cardiovascular events in older people specifically due to triptan use 1
• If triptans are considered, regular blood pressure monitoring is advised 1

Third-Line Options

• CGRP antagonists (gepants) such as rimegepant or ubrogepant may be considered for patients who don't respond to or cannot tolerate NSAIDs, as they don't have vascular contraindications 3
• Antiemetics like prochlorperazine can effectively relieve both headache pain and nausea 1, 2

Special Considerations for Elderly Patients

Age-Related Concerns

• Migraine often remits with older age, and onset after age 50 should raise suspicion of secondary causes 1
• Consider comorbidities and potential drug interactions, which are more common in elderly patients 1
• Monitor for adverse effects, to which older people are generally more susceptible 1

Medication Overuse Prevention

• Limit acute treatments to no more than twice weekly to prevent medication overuse headache 2, 3
• Closely monitor analgesic use as overuse may lead to rebound headaches 1

Non-Pharmacological Approaches

• Consider non-pharmacological therapies such as neuromodulatory devices, biobehavioural therapy, or acupuncture as adjuncts or alternatives when medications are contraindicated 1
• These approaches may be particularly valuable in elderly patients who may be more sensitive to medication side effects 1

Preventive Treatment Considerations

• If the patient experiences frequent or disabling attacks (≥2 days per month) despite optimized acute treatment, consider preventive therapy 1
• Beta blockers (with careful monitoring), candesartan, or amitriptyline (at lower doses) may be considered for prevention in elderly patients 1, 2
• CGRP monoclonal antibodies could be considered as third-line preventive medications when other options fail 1

Remember that in elderly patients, the principle "start low, go slow" is particularly important when initiating any migraine medication to minimize adverse effects 1, 2.