Is naproxen (Nonsteroidal Anti-Inflammatory Drug) safe for an elderly woman with atrial fibrillation (Afib) to treat migraines?

Naproxen Safety in Elderly Women with Atrial Fibrillation for Migraine Treatment

Naproxen should be used with extreme caution—if at all—in an elderly woman with atrial fibrillation for migraine treatment, as NSAIDs including naproxen are identified as modifiable bleeding risk factors that should be addressed in AF patients on anticoagulation, and elderly patients face compounded risks from both the NSAID itself and necessary stroke prevention therapy. 1

Primary Safety Concerns

Bleeding Risk with Anticoagulation

• NSAIDs including naproxen are explicitly listed as correctable risk factors for bleeding in the HAS-BLED scoring system used to assess bleeding risk in AF patients. 1
• The 2012 ESC guidelines specifically state that "concomitant drugs (aspirin, NSAIDs, etc.)" should be addressed as modifiable bleeding risks in AF patients requiring anticoagulation. 1
• Elderly AF patients (≥75 years) already have approximately twice the risk of serious bleeding complications during anticoagulation compared with younger patients. 1

Anticoagulation Requirements in Elderly AF Patients

• An elderly woman with AF almost certainly requires oral anticoagulation for stroke prevention, as advanced age (per decade) carries a relative risk of 1.4 for ischemic stroke, and nearly half of AF-associated strokes occur in patients over age 75. 1
• AF is the most frequent cause of disabling stroke in elderly women specifically. 1
• Anticoagulation with warfarin (INR 2.0-3.0) or DOACs is recommended for patients with AF who have risk factors including age ≥75 years. 1

Compounded Risk Profile

• The combination of necessary anticoagulation PLUS NSAID use creates a significantly elevated bleeding risk that is particularly dangerous in the elderly. 1
• Poorly controlled hypertension and concomitant aspirin or NSAID use confer higher bleeding risk during anticoagulation. 1
• Age per se increases bleeding risk, but when combined with NSAIDs, the risk becomes substantially more concerning. 1

Alternative Migraine Treatment Strategies

Acute Treatment Options

• Acetaminophen (paracetamol) is the safest drug for symptomatic treatment of migraine in the elderly and should be first-line. 2
• Triptans are generally not recommended in elderly patients even in the absence of cardiovascular or cerebrovascular risk. 2
• NSAID use should be limited because of potential gastrointestinal adverse effects, and in this case, the bleeding risk with concurrent anticoagulation. 2

Prophylactic Treatment (Preferred Approach)

Given the risks of acute NSAID therapy, prophylactic treatment should be strongly considered as the primary management strategy:

• Beta-blockers (propranolol 80-240 mg/day, metoprolol 50-100 mg twice daily, or atenolol 25-100 mg twice daily) are first-line prophylactic agents and may provide dual benefit if the patient has hypertension. 3, 4
• Topiramate 50-100 mg daily is first-line prophylaxis. 3
• Candesartan 16-32 mg daily is first-line prophylaxis, particularly useful if hypertensive. 3
• Amitriptyline 10-100 mg at night is second-line prophylaxis. 3, 4
• Flunarizine 5-10 mg daily is second-line prophylaxis where available. 3, 4

Clinical Decision Algorithm

Step 1: Assess Anticoagulation Status

• If the patient is on anticoagulation (warfarin or DOAC): Avoid naproxen due to significantly increased bleeding risk. 1
• If not yet anticoagulated: Initiate appropriate anticoagulation based on stroke risk stratification, then avoid naproxen. 1

Step 2: Implement Safer Acute Treatment

• Use acetaminophen as first-line acute treatment. 2
• Avoid triptans given elderly status and cardiovascular considerations. 2

Step 3: Initiate Prophylactic Therapy

• Start beta-blocker prophylaxis (if no contraindications like COPD, heart failure, or peripheral vascular disease). 3, 4
• Consider topiramate or candesartan as alternatives. 3
• This approach reduces migraine frequency and eliminates the need for repeated NSAID exposure. 3, 4

Critical Pitfalls to Avoid

• Never combine NSAIDs with anticoagulation in elderly patients without compelling justification and close monitoring. 1
• Do not assume that because naproxen is effective for migraine (NNT 11 for pain-free at 2 hours) that it is appropriate in this high-risk population. 5
• Do not use aspirin as an alternative—it carries similar bleeding risks to anticoagulation, especially in the elderly. 1
• Avoid the misconception that short-term NSAID use is safe; even brief exposure increases bleeding risk in anticoagulated patients. 1

Evidence Quality Considerations

The recommendation against NSAID use in anticoagulated AF patients comes from Class I, Level A evidence from the 2012 ESC guidelines, which explicitly identify NSAIDs as modifiable bleeding risk factors. 1 This is reinforced by the 2024 narrative review on drug-induced AF emphasizing the importance of reviewing pharmacological history and addressing drug-related risks. 1

The evidence for naproxen's efficacy in migraine (moderate quality, NNT 11) does not outweigh the well-established bleeding risks in this specific population. 5, 6