Acute and Preventive Migraine Treatment in an Elderly Woman with Coronary Artery Disease
Acute Treatment Options
For acute migraine attacks, NSAIDs combined with an antiemetic represent the safest and most effective first-line therapy in this patient. 1, 2
First-Line Acute Therapy: NSAIDs + Antiemetic
- Naproxen sodium 500–825 mg or ibuprofen 400–800 mg should be administered at migraine onset, ideally when pain is still mild. 1, 2
- Add metoclopramide 10 mg (oral or IV if severe) 20–30 minutes before or with the NSAID to provide synergistic analgesia beyond its antiemetic effect through central dopamine receptor antagonism. 2
- Prochlorperazine 10 mg IV is an equally effective alternative to metoclopramide with comparable efficacy for both headache pain and nausea. 2
- Limit NSAID use to no more than 2 days per week to prevent medication-overuse headache. 1, 2
Second-Line Acute Therapy: CGRP Antagonists (Gepants)
If NSAIDs fail after 2–3 migraine episodes, escalate to gepants rather than triptans given her coronary artery disease. 1, 3
- Rimegepant 75 mg orally or ubrogepant 50–100 mg orally are the preferred alternatives because they have no vasoconstrictor activity and are safe in cardiovascular disease. 2, 3, 4
- Gepants achieve pain freedom in approximately 21% of patients at 2 hours (vs. 11% with placebo) and pain relief in 59% (vs. 43% with placebo). 4
- Zavegepant nasal spray is another option when oral administration is limited by nausea. 2
- Limit gepant use to no more than 8 migraine attacks per 30-day period to prevent medication overuse. 2
Third-Line Acute Therapy: Lasmiditan (Ditan)
- Lasmiditan 50–200 mg orally is a 5-HT1F receptor agonist without vasoconstrictor activity, making it safe in coronary artery disease. 2, 3
- Critical safety warning: Patients must not drive or operate machinery for at least 8 hours after taking lasmiditan due to CNS effects (dizziness, vertigo, somnolence). 2
Parenteral Options for Severe Attacks
- IV metoclopramide 10 mg plus IV ketorolac 30 mg provides rapid relief for severe attacks requiring emergency treatment. 2
- Dihydroergotamine (DHE) 0.5–1.0 mg IV or intranasal has good evidence for efficacy but is contraindicated with concurrent beta-blocker use (carvedilol) and in coronary artery disease. 1, 2, 3
Medications to Absolutely Avoid
Triptans are strictly contraindicated in this patient due to coronary artery disease. 1, 2
- Triptans cause coronary vasoconstriction and have been associated with myocardial infarction even in patients without known coronary disease. 5, 6
- The contraindication is absolute regardless of the specific triptan formulation. 1
Opioids (codeine, hydromorphone, oxycodone) should never be prescribed for migraine due to limited efficacy, high risk of medication-overuse headache, potential for dependence, and poor long-term outcomes. 2
Preventive Treatment Options
Preventive therapy is strongly indicated because she has recurrent headaches requiring treatment. 1, 7
First-Line Preventive Therapy: Continue Optimized Beta-Blocker
Since she is already on maximal carvedilol for hypertension, this serves as her first-line migraine preventive. 1, 7
- Carvedilol is an effective antihypertensive in elderly patients with no adverse lipid effects and acceptable tolerability. 8, 9
- Beta-blockers without intrinsic sympathomimetic activity (propranolol, metoprolol, atenolol, timolol) are first-line preventives with strong evidence. 1, 7
- Carvedilol's beta-blocking properties provide migraine prophylaxis while managing her hypertension. 1, 7
Second-Line Preventive Therapy: Add Topiramate or Amitriptyline
If carvedilol alone does not reduce migraine frequency by ≥50% after 2–3 months, add topiramate or amitriptyline. 1, 7
- Topiramate 50–100 mg/day (typically 50 mg twice daily) is the strongest evidence-based oral preventive for both episodic and chronic migraine. 7
- Amitriptyline 30–150 mg/day is preferred if she has comorbid depression, anxiety, or sleep disturbances. 1, 7
- Allow an adequate trial of 2–3 months at target dose before judging efficacy. 7
Third-Line Preventive Therapy: CGRP Monoclonal Antibodies
If two oral preventives fail, escalate to CGRP monoclonal antibodies. 1, 7
- Erenumab, fremanezumab, or galcanezumab administered monthly via subcutaneous injection are third-line options. 1, 7
- These agents are safe in cardiovascular disease with no vasoconstrictor activity, though erenumab has been associated with hypertension requiring monitoring. 10
- Efficacy assessment requires 3–6 months of treatment. 7
- Cost is significantly higher ($5,000–$6,000 annually) compared to oral agents. 7
Alternative Preventive Options
- Candesartan (angiotensin receptor blocker) is a first-line preventive particularly useful in hypertensive patients, though she is already on maximal carvedilol. 1, 7
- Flunarizine 5–10 mg once daily is an effective second-line agent where available, but carries risk of depression and extrapyramidal symptoms in elderly patients. 7
Medications to Avoid in Preventive Therapy
Sodium valproate/divalproex is contraindicated in women of childbearing potential due to teratogenic risk, though this may be less relevant in an elderly patient. 1, 7
Non-Pharmacological Adjuncts
Consider neuromodulatory devices, biobehavioral therapy, or acupuncture as adjuncts to medication. 1
- These options are particularly valuable when medication side effects are limiting or as stand-alone treatments when medications are contraindicated. 1
- Cognitive behavioral therapy, biofeedback, and relaxation training have proven efficacy for migraine prevention. 7
Critical Pitfalls to Avoid
Do not prescribe triptans despite their superior efficacy because coronary artery disease is an absolute contraindication due to coronary vasoconstriction risk. 1, 5, 6
Do not allow acute medication use to exceed 2 days per week as this creates medication-overuse headache, paradoxically increasing headache frequency and leading to daily headaches. 1, 2
Do not substitute opioids or butalbital compounds as rescue medications because they have questionable efficacy, cause dependency, and perpetuate rebound headaches. 2
Monitor blood pressure closely if using CGRP antagonists (gepants or monoclonal antibodies) because erenumab has been associated with hypertension. 10
Screen for depression before initiating flunarizine in elderly patients because it may exacerbate depression and cause extrapyramidal symptoms. 7