Is it safe to give Naproxen (Nonsteroidal Anti-Inflammatory Drug) to the elderly for headaches?

Naproxen for Headache in the Elderly: Safety Considerations

Naproxen can be used for headache in elderly patients, but requires significant caution due to increased risks of gastrointestinal bleeding, renal toxicity, and cardiovascular complications that are substantially higher in this age group. 1

Key Safety Concerns in Elderly Patients

Gastrointestinal Risks

• NSAIDs including naproxen carry a strong recommendation to avoid in elderly patients at high risk, particularly those ≥75 years, due to increased risk of upper gastrointestinal bleeding and peptic ulcer perforation. 1
• The 2019 American Geriatrics Society Beers Criteria specifically lists nonselective NSAIDs with a "strong" recommendation to avoid, based on high-quality evidence. 1
• Risk factors requiring particular caution include: history of peptic ulcer disease, concurrent use of anticoagulants, antiplatelet agents (including low-dose aspirin), corticosteroids, or SSRIs. 1
• If NSAID use is deemed necessary despite risks, concomitant proton-pump inhibitor therapy should be initiated for gastroprotection. 1

Renal and Cardiovascular Toxicity

• Naproxen can worsen renal function in elderly patients, particularly those with chronic kidney disease (CrCl <30 mL/min), heart failure, or taking other nephrotoxic drugs. 1
• NSAIDs impair blood pressure control and can precipitate or worsen heart failure in elderly patients. 1
• The drug should be avoided in patients with moderate to severe renal impairment. 2

Altered Pharmacokinetics in the Elderly

• Although total plasma naproxen concentration remains unchanged in elderly patients, the unbound (active) fraction increases significantly, leading to higher risk of adverse effects. 2, 3
• Elderly patients (mean age 84 years) demonstrate significantly higher pre-dose concentrations (60.1 vs. 43.3 μg/mL) and reduced clearance (315 vs. 628 mL/h) compared to younger patients. 3
• Free naproxen concentration is significantly elevated in elderly patients (141 vs. 89.8 ng/mL), increasing toxicity risk despite similar protein binding. 3

Clinical Recommendations for Use

When Naproxen May Be Considered

• For migraine headaches specifically, naproxen is recommended as first-line therapy when NSAIDs are appropriate, but with careful patient selection. 1, 4
• Naproxen 500 mg is commonly used as oral rescue therapy for older adults with migraine or tension headaches. 5, 6
• The drug should be reserved for patients without contraindications and used at the lowest effective dose for the shortest duration. 2

Dosing Adjustments Required

• Start therapy at the lower end of the dosage range in elderly patients. 2, 3
• For acute pain management: initial dose 500 mg, followed by 500 mg every 12 hours or 250 mg every 6-8 hours as required. 2
• Maximum initial daily dose should not exceed 1250 mg, with subsequent daily doses not exceeding 1000 mg. 2
• Some dosage adjustment may be required in elderly patients, and it is prudent to use the lowest effective dose. 2

Monitoring Requirements

• Monitor renal function and blood pressure regularly during therapy. 1
• Watch for signs and symptoms of gastrointestinal bleeding (advise patients about warning signs). 1
• Limit acute treatment use to no more than twice weekly to prevent medication overuse headache. 1, 4

Safer Alternatives to Consider

For Acute Headache Treatment

• Acetaminophen (paracetamol) is the safest drug for symptomatic treatment of migraine in the elderly, though less effective than NSAIDs. 7
• Hydroxyzine can be combined with naproxen for additional benefit in selected patients. 5, 6
• Triptans are generally not recommended as first-line in elderly due to cardiovascular risks, though no robust evidence supports increased cerebrovascular events specifically from triptan use. 1

For Preventive Therapy

• If headaches occur ≥2 days per month despite optimized acute treatment, consider preventive therapy with beta-blockers (metoprolol, propranolol), topiramate, or candesartan as first-line options. 1, 4
• Amitriptyline at low doses may be considered as second-line, though anticholinergic effects limit use in elderly. 1

Critical Pitfalls to Avoid

• Never combine naproxen with anticoagulants without gastroprotection, as this increases bleeding risk 3- to 6-fold. 1
• Avoid in patients with heart failure (can precipitate acute decompensation), uncontrolled hypertension, or significant renal impairment. 1
• Do not use in patients with history of NSAID-induced gastrointestinal bleeding or peptic ulcer disease without compelling indication and gastroprotection. 1
• Recognize that new-onset headache after age 50 should raise suspicion for secondary causes (temporal arteritis, intracranial pathology) before attributing to primary headache disorder. 1

The decision to use naproxen in elderly patients must weigh the modest efficacy (NNT of 11 for pain-free response at 2 hours for migraine) against substantially elevated risks of serious adverse events in this population. 8 When safer alternatives exist or contraindications are present, naproxen should be avoided. 1