What is the best treatment approach for a 60-year-old female with new onset migraines?

New Onset Migraines in a 60-Year-Old Female

Before initiating migraine treatment in a 60-year-old woman with new onset headaches, you must first rule out secondary causes—this age group has higher risk for serious pathology including temporal arteritis, mass lesions, and cerebrovascular disease that can mimic migraine. 1

Critical Initial Evaluation

Once secondary causes are excluded and migraine is confirmed, proceed with treatment using a stepped-care approach:

Acute Treatment Algorithm

First-Line: NSAIDs

Start with NSAIDs as your initial therapy for acute attacks. 1

• Aspirin, ibuprofen, or diclofenac potassium have the strongest evidence for first-line use 1
• Acetaminophen has inferior efficacy and should only be used if NSAIDs are contraindicated 1
• Take medication early in the attack when headache is still mild for maximum effectiveness 1

Second-Line: Add a Triptan

If NSAIDs provide inadequate relief, add a triptan to the NSAID regimen. 1

• The 2025 American College of Physicians guideline provides a strong recommendation to add a triptan to an NSAID for moderate to severe migraine not responding adequately to NSAIDs alone 1
• All triptans have well-documented effectiveness; sumatriptan 50-100 mg achieves headache response (reduction to mild or no pain) in 50-62% of patients at 2 hours versus 17-27% with placebo 1, 2
• Critical caveat for this 60-year-old patient: Triptans are contraindicated in cardiovascular disease due to vasoconstrictive properties 3—assess cardiovascular risk factors before prescribing
• If one triptan fails, try another—individual response varies 1

Adjunctive Antiemetic Therapy

Treat nausea proactively, not just when vomiting occurs. 1

• Nausea is one of the most disabling symptoms of migraine and warrants treatment even without vomiting 1
• Consider antiemetics for patients with significant nausea as part of their symptom complex 1

Preventive Therapy Considerations

Evaluate this patient for preventive therapy if she experiences:

• ≥2 disabling attacks per month 4, 3
• Inadequate response to optimized acute treatment 4, 3
• Use of acute medications >2 days per week (to prevent medication overuse headache) 3

First-Line Preventive Options (if indicated):

• Propranolol 80-240 mg/day 1
• Amitriptyline 30-150 mg/day 1
• Topiramate or valproate 1

Critical Pitfalls to Avoid

Medication Overuse Headache Prevention:

• Limit NSAIDs/acetaminophen to <15 days/month 3
• Limit triptans to <10 days/month 3
• Never use opioids or butalbital for migraine—they cause dependency and medication overuse headache 3

Age-Specific Concerns:

• New onset migraine at age 60 is atypical and warrants thorough secondary cause exclusion 1
• Cardiovascular risk assessment is mandatory before prescribing triptans in this age group 3
• Consider comorbidities (hypertension, cardiovascular disease) when selecting both acute and preventive therapies 1

Patient Education Essentials

Provide comprehensive education about:

• Migraine as a chronic neurological disease requiring ongoing management 1
• Correct medication use: take acute medications early in the attack for best efficacy 1, 3
• Medication overuse risks and frequency limits 1
• Realistic expectations: goal is reducing attack frequency, duration, and intensity to restore function—not complete elimination 1