Treatment of Refractory Migraine in an Elderly Female After Ubrelvy Failure
For an elderly female with a 2-day migraine unresponsive to Ubrelvy, immediately initiate NSAIDs (ibuprofen 400-800 mg or naproxen sodium 500-825 mg) as first-line rescue therapy, and simultaneously begin preventive therapy given the prolonged attack duration suggests inadequate migraine control. 1
Immediate Acute Management
NSAIDs are the safest and most effective first-line option for acute migraine treatment in elderly patients, with careful monitoring for gastrointestinal and cardiovascular risks. 1 Specifically:
- Ibuprofen 400-800 mg or naproxen sodium 500-825 mg should be administered immediately 1, 2
- Add antiemetics as needed for nausea 2
- Acetaminophen is the safest alternative when NSAIDs are contraindicated, though it should be combined with other agents for optimal efficacy 1, 3
Critical Medication Avoidance in Elderly Patients
- Triptans should generally be avoided in elderly patients due to high prevalence of cardiovascular disease, though no robust evidence proves increased cardiovascular events from triptan use per se 1, 2, 3
- Butalbital-containing medications are explicitly contraindicated due to dependency risk, medication-overuse headache, cognitive impairment, falls risk, and lack of proven efficacy 1
- Opioids and barbiturates should not be used due to questionable efficacy with considerable adverse effects and dependency risk 4
Transition to Preventive Therapy
The 2-day duration of this migraine attack is a clear indication to initiate preventive therapy immediately, as this pattern suggests inadequate migraine control and risk for medication-overuse headache. 1 The threshold for preventive therapy is requiring acute treatment more than 2 days per month. 1, 4, 2
First-Line Preventive Options
Beta-blockers are appropriate first-line agents, particularly if hypertension coexists: 1, 2
- Metoprolol 100-200 mg daily 1
- Propranolol 80-240 mg daily 1
- Atenolol or bisoprolol are alternatives 4, 2
Topiramate 50-100 mg daily has strong evidence for prevention, though requires monitoring for cognitive side effects (cognitive inefficiency, paresthesia, fatigue) and is contraindicated in nephrolithiasis, pregnancy, and glaucoma. 1, 4, 2 Start at 25 mg with weekly dose escalation to 50 mg twice daily. 2
Candesartan 16-32 mg daily offers effectiveness with good tolerability, particularly beneficial in hypertensive patients. 1, 4
Second-Line Preventive Options
If first-line agents fail or are contraindicated: 4
- Flunarizine 5-10 mg oral once daily (avoid in patients with Parkinsonism or depression) 4
- Amitriptyline 10-100 mg at night or nortriptyline for patients with coexisting anxiety or depression, though use caution due to risks of cognitive impairment, urinary retention, and cardiac arrhythmia in elderly 4, 5
Third-Line Options for Refractory Cases
CGRP monoclonal antibodies should be considered when first and second-line agents fail: 1, 4, 2
- Erenumab 70 or 140 mg subcutaneous once monthly 4
- Fremanezumab 225 mg subcutaneous once monthly or 675 mg quarterly 4
- Eptinezumab 100 or 300 mg intravenous quarterly 4
Medication-Overuse Headache Prevention
Limit acute medications to no more than 2 days per week to prevent medication-overuse headache. 1 Specifically:
Treatment Assessment Timeline
- Assess efficacy of oral preventive medications after 2-3 months at therapeutic dose 4, 2
- Consider pausing treatment after 6-12 months of successful control to determine if preventive therapy can be stopped 4
- Encourage headache diary use to track frequency, severity, medication use, and identify triggers 2
Common Pitfalls to Avoid
- Do not abandon treatment prematurely - efficacy takes weeks to months to establish 4
- Start with lower medication doses and titrate slowly in elderly patients 2
- Consider comorbidities and potential drug interactions given greater use of drugs for concomitant diseases in the elderly 2, 3
- Monitor for cardiovascular and gastrointestinal risks with NSAID use 1, 6