What are the recommended treatments for migraines in elderly patients?

Treatment of Migraines in Elderly Patients

For elderly patients with migraine, NSAIDs plus antiemetics remain first-line acute treatment, while beta-blockers (with careful cardiovascular monitoring), topiramate, or candesartan are first-line preventive options, though comorbidities and increased susceptibility to adverse effects require heightened vigilance. 1

Critical Diagnostic Consideration

• New-onset migraine after age 50 should raise suspicion for secondary headache disorders, as migraine typically remits with age while incidence of dangerous secondary headaches increases 1
• Rule out stroke, temporal arteritis, mass lesions, and other structural causes before treating as primary migraine 1

Acute Treatment Approach

First-Line: NSAIDs with Antiemetics

• Start with NSAIDs (ibuprofen, naproxen sodium, or aspirin) combined with an antiemetic if nausea is present 1, 2
• Naproxen 500-825 mg at onset is effective, with maximum 1.5 g/day, limited to no more than twice weekly to prevent medication-overuse headache 2
• Monitor for gastrointestinal bleeding risk and renal function, as elderly patients are more susceptible to NSAID-related adverse effects 1

Second-Line: Triptans (With Important Caveats)

• Triptans can be used in elderly patients despite cardiovascular concerns, as no robust evidence supports increased cerebrovascular or cardiovascular events from triptan use per se 1
• However, regularly monitor blood pressure and periodically assess cardiovascular risk factors (diabetes, hypertension, smoking, obesity, family history of CAD) in elderly patients using triptans 1, 3
• If three consecutive attacks fail with NSAIDs, switch to triptans (sumatriptan, rizatriptan, or zolmitriptan) 1
• Cardiovascular evaluation is recommended before initiating triptans in geriatric patients with cardiovascular risk factors 3

Alternative Routes for Nausea/Vomiting

• Intranasal sumatriptan (5-20 mg) or subcutaneous sumatriptan (6 mg) for patients with significant nausea or vomiting 2, 4
• Subcutaneous formulation provides highest efficacy (59% pain-free at 2 hours) but with higher adverse event rates 2

Preventive Treatment Approach

Indications for Prevention

• Consider preventive therapy if patient experiences ≥2 migraine days per month with significant disability despite optimized acute treatment 1, 5
• Also indicated if using acute medications more than twice weekly (risk of medication-overuse headache) 5, 2

First-Line Preventive Medications

Beta-blockers:

• Propranolol (80-240 mg/day), metoprolol, atenolol, or bisoprolol 1, 5
• Monitor for bradycardia, hypotension, and worsening of heart failure or COPD in elderly patients 1

Topiramate:

• 50-100 mg daily (typically 50 mg twice daily) 1, 5
• Contraindicated in nephrolithiasis, glaucoma 1
• Monitor for cognitive side effects, which may be more pronounced in elderly patients 1

Candesartan:

• 16-32 mg daily 1, 5
• Particularly useful for elderly patients with comorbid hypertension 5

Second-Line Preventive Medications

• Amitriptyline (10-100 mg at night): effective but monitor for anticholinergic effects (confusion, urinary retention, falls risk) in elderly 1, 5
• Flunarizine (5-10 mg daily): effective where available, but avoid in patients with Parkinsonism or depression 1
• Sodium valproate: contraindicated in women of childbearing potential; can be used in elderly men (600-1500 mg daily) 1

Third-Line: CGRP Monoclonal Antibodies

• Erenumab (70-140 mg subcutaneous monthly), fremanezumab (225 mg monthly or 675 mg quarterly), or eptinezumab (100-300 mg IV quarterly) 1, 5
• Fremanezumab not recommended in patients with history of stroke, subarachnoid hemorrhage, coronary heart disease, inflammatory bowel disease, COPD, or impaired wound healing 1
• Consider when first- and second-line options have failed or are contraindicated 1, 5

Implementation Strategy

Dosing Principles

• Start with low doses and titrate slowly in elderly patients due to increased susceptibility to adverse effects 1
• Allow adequate trial period of 2-3 months before concluding treatment failure for oral preventive medications 1, 5
• For CGRP antibodies, assess efficacy only after 3-6 months 5

Monitoring Requirements

• Regular blood pressure monitoring for patients on triptans 1
• Periodic cardiovascular risk assessment 1, 3
• Headache diary to track frequency, severity, medication use, and identify medication-overuse patterns 1

Critical Pitfalls to Avoid

• Do not dismiss new-onset headache after age 50 as migraine without thorough evaluation for secondary causes 1
• Do not allow acute medication use more than twice weekly, as this leads to medication-overuse headache 5, 2
• Do not overlook polypharmacy concerns and drug-drug interactions common in elderly patients 1
• Do not use combined hormonal contraceptives (not applicable to most elderly, but relevant for perimenopausal women with migraine with aura due to stroke risk) 1
• Do not prescribe opioids routinely, as they lead to dependency, rebound headaches, and loss of efficacy 1, 2

Adjunctive and Non-Pharmacological Options

• Consider neuromodulatory devices, biobehavioral therapy, or acupuncture as adjuncts or stand-alone treatments when medications are contraindicated 1, 5
• These options may be particularly valuable in elderly patients with multiple comorbidities limiting medication options 1, 5