What is the diagnosis and treatment for a 71-year-old female patient experiencing migraines (episodic headaches with neurological symptoms)?

From the Guidelines

For a 71-year-old female with migraines, I recommend starting with a low-dose triptan such as sumatriptan 25-50mg as needed for acute attacks, with careful cardiovascular assessment first due to her age, as suggested by the most recent guidelines 1.

Acute Treatment

• The 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline for the management of headache recommends eletriptan, frovatriptan, rizatriptan, sumatriptan, or zolmitriptan for the short-term treatment of migraine 1.
• Aspirin-acetaminophen-caffeine is also recommended for the short-term treatment of migraine 1.
• Rimegepant or ubrogepant may be considered as alternatives for acute treatment in older patients with cardiovascular concerns 1.

Preventive Therapy

• Preventive therapy should be considered if she experiences frequent migraines (more than 4 per month) 1.
• First-line options for preventive therapy include candesartan, telmisartan, erenumab, fremanezumab, or galcanezumab, as recommended by the 2023 guideline 1.
• Other options such as propranolol, topiramate, or amitriptyline may be considered, but with careful monitoring of side effects due to her age 1.

Non-Pharmacological Approaches

• Trigger identification and avoidance, regular sleep patterns, stress management, and adequate hydration are important non-pharmacological approaches to manage migraines.
• Regular follow-up is essential to assess treatment efficacy and adjust the regimen as needed, taking into account age-related considerations such as increased risk of medication side effects and drug interactions 1.

From the FDA Drug Label

The efficacy of sumatriptan tablets in the acute treatment of migraine headaches was demonstrated in 3, randomized, double-blind, placebo-controlled trials. Patients enrolled in these 3 trials were predominately female (87%) and Caucasian (97%), with a mean age of 40 years (range of 18 to 65 years).

The patient in question is a 71-year-old female, which is outside the age range of the patients in the clinical trials for sumatriptan. There is no direct information in the drug label to support the use of sumatriptan in a 71-year-old female. The FDA drug label does not answer the question.

From the Research

Treatment Options for Migraines

• Eletriptan is an effective treatment option for acute migraine attacks in adults, with a rapid onset of action and superiority over placebo as early as 30 minutes after administration 2, 3.
• Eletriptan 40 and 80 mg have been shown to be consistently superior to ergotamine/caffeine and have a favorable efficacy profile compared to other triptans 2, 3.
• Topiramate is a first-line option for migraine prevention, with a large body of evidence supporting its efficacy in reducing migraine frequency and acute medication use, improving quality of life, and reducing disability in patients with episodic and chronic migraine 4.

Considerations for Treatment

• Eletriptan is generally well tolerated, but its concomitant administration with CYP3A4-potent inhibitors should be carefully evaluated due to potential pharmacokinetic interactions 5.
• Topiramate has a favorable weight profile and is effective in migraine prevention, but its use requires careful consideration of potential side effects, including paresthesia, cognitive problems, and metabolic effects 4.
• Anti-epileptic drugs, including topiramate and valproate, can be effective in migraine prophylaxis, but their use requires careful consideration of potential serious side effects, particularly in women of childbearing potential 6.

Specific Considerations for a 71-Year-Old Female

• The efficacy and safety of eletriptan and topiramate in older adults have not been specifically addressed in the provided studies, but their use in this population would require careful consideration of potential age-related changes in pharmacokinetics and pharmacodynamics.
• The potential for drug interactions with other medications commonly used in older adults should also be carefully evaluated when considering the use of eletriptan or topiramate in this population.