By Lindsay Slowiczek, PharmD

September 2017

Long-Term Care Updates

www.creighton.edu/pharmerica

Migraines are often considered to be a condition affecting younger or middle-aged patients, during which patients experience

episodic, severe headaches, often accompanied by nausea, light sensitivity, or sensory disturbances.1 However, a recent National

Health Interview Survey published in (2017) found that 3.4% of men and 6.3% of

women aged 75 years or older experienced a severe headache or migraine in a given 3 month period.2 While the frequency and

intensity of migraines do decrease with advanced age, between 2-3% of first migraine attacks are reported in patients 50 years

or older.3 A survey which compared migraine characteristics in patients aged 60 to 70 years to patients between 20 and 40 years

of age found that a similar proportion of patients sought treatment for migraine attacks, but migraines in the older age group

were characterized as less “typical”. Older patients reported migraines with fewer unilateral and associated symptoms, such as

photophobia or nausea, but with more frequent neck pain, lacrimation, and rhinorrhea. Elderly patients with chronic headaches

or migraines also have a higher risk for depression or functional impairment than younger

patients, emphasizing the importance of diagnosis and treatment in this population.4 While

atypical symptom presentation may make correct diagnosis a greater challenge, elderly patients

often have better responses to pharmacological treatment. 5,6 The following newsletter will

review migraine prevention recommendations, with particular focus on management in the

elderly population.

There are several modifiable causes of migraines in the elderly that may be addressed to help

decrease the frequency and severity of migraine attacks. Lifestyle and nonpharmacological

migraine triggers include lack of sleep or excessive sleep, blinding or fluorescent lighting, dietary

triggers, physical exercise, and psychological stress.7 Several medications that have been

associated with, or known to aggravate, migraines are listed in Box 1. When appropriate,

reducing the dosages of offending agents, or discontinuing their use if no longer needed, may

decrease the frequency or severity of migraine attacks. Eliminating environmental or dietary

triggers, reducing psychological stress, and optimizing sleep and physical activity patterns may

also improve migraine symptomology.8

Migraines can also result from overuse of medication intended to treat headaches. The regular use of acute headache medication,

defined as 15 or more uses per month for at least 3 months, can cause Medication Overuse Headache (MOH), which often

progresses to episodic migraine in elderly patients.6 In fact, approximately 1-2% of those over the age of 65 suffer from MOH

due to chronic overuse of analgesics or other headache remedies.9 The most common culprits are triptans, barbiturates, caffeine,

and other analgesics, with triptans possibly progressing to MOH at a faster rate than other headache medications.10 When

evaluating a patient’s medication regimen, it is important to obtain a thorough history of both prescription and non-prescription

medications, in order to rule out MOH or to identify overuse of analgesics. MOH is most successfully treated by discontinuing

the overused agent and assessing the need for a migraine prophylactic agent.11

Uncontrolled hypertension can also cause migraines or complicate their treatment. Chronically elevated blood pressure can alter

normal and adaptive endothelial responses to changing cerebral blood flow, which can increase the frequency or severity of

migraines.12 A large, population-based study found that elevated diastolic blood pressure was positively correlated with risk of

migraine, particularly for women, although elevated systolic blood pressure and pulse were not associated with this increased

risk.13 Uncontrolled hypertension may also be associated with the transformation from episodic to chronic migraine in some

patients.12 Due to the possible association between uncontrolled blood pressure and migraine, a patient’s blood pressure

medication regimen should be optimized to rule out hypertension as a cause and minimize the severity or frequency of attacks.

Prevention options and recommendations for elderly patients are similar to those for younger migraineurs, but consideration

must be given to clinical scenarios unique to the geriatric population. The American Academy of Neurology (AAN) and the

American Headache Society recommend antiepileptic drugs, beta-blockers, antidepressants, and triptans as effective or probably

effective migraine prevention options in the general population. It is important to note that triptans are recommended in these

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Antibacterials (e.g. trimethoprim/sulfamethoxazole, tetracycline)

Antihypertensives (e.g. nifedipine, enalapril)

Antiparkinson drugs (e.g. amantadine, levodopa)

H2 receptor antagonists (e.g. cimetidine, ranitidine)

Sedatives (e.g. benzodiazepines, hypnotics)

Stimulants (e.g. caffeine, methylphenidate)

Vasodilators (e.g. isosorbide dinitrate, nitroglycerin)

guidelines for short term prophylaxis of menstrually-related migraines, only.14 Selection of a migraine prevention medication for

elderly patients should be patient-specific, based on complicating comorbidities, medication tolerability, adverse effect profile,

and concomitant medications. Table 1 below outlines the appropriate use and clinical considerations for pharmacological

prevention options in elderly patients. A more comprehensive list of drug-drug interactions relevant to this patient population

can be found in the July 2017 Long-Term Care Updates newsletter, “Common Drug Interactions in Geriatric Patients”.

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Definitions: Effective = Established efficacy based on results of 2 or more well-designed randomized controlled trials in the representative population;Probably Effective = based on 1 well-designed randomized controlled trial in the representative population or 2 randomized controlled trials lackingmethodological criteria or lacking elements of applicability to population

Preventative Agent Useful with ComorbidConditions Cautions or Contraindications Common Drug-

Drug Interactions

Antiepileptic Drugs(AEDs)

Effective:divalproex,valproate,topiramate

Epilepsy, neuropathicpain, trigeminalneuralgia, psychiatricdisorders

Topiramate: tremorreduction

Divalproex/valproate: hepaticimpairment, CNS depression,pancreatitis, weight gain

Topiramate: weight loss,peripheral paraesthesias, visualdisturbances (including narrow-angle glaucoma)

Other AED’s,ritonavir,carbapenemantibiotics, CNSdepressants,warfarin

Beta-blockers

Effective:metoprolol,propranolol, timolol

Probably Effective:atenolol, nadolol

Hypertension

Propranolol: limbessential tremor andhead tremor

Chronic obstructive pulmonarydisease, acute heart failure,bradycardia, hypotension,asthma, diabetes, depression,peripheral vascular disease

Antiarrhythmicagents, calciumchannel blockers

Antidepressants

Probably Effective:amitriptyline,venlafaxine

Mood disorders,depression, generalizedanxiety

Amitriptyline: insomnia

Antidepressants: may requirerenal or hepatic dosagereductions; potential for symptomof inappropriate antidiuretichormone secretion

Amitriptyline: strongrecommendation in 2015 BeersCriteria to avoid use due tosedation, anticholinergic effects,and orthostatic hypotension15;may also cause confusion, weightgain, increased fall risk

Venlafaxine: narrow angleglaucoma, hypertension,serotonin syndrome, weight loss

Monoamine oxidaseinhibitors; CYPenzyme interactions

The migraine prevention options listed in Table 1 are not all-inclusive; alternative agents described in the AAN’s 2012 guidelines

include angiotensin-converting-enzyme inhibitors, angiotensin receptor blockers, gabapentin, and clonidine, among others. However,

these agents are listed as “possibly effective” alternative agents, due to inadequate or conflicting evidence to support their use.14

While the American Medical Directors Association do not specifically address therapeutic options for migraine prophylaxis, they do

recommend pharmacists thoroughly review a patient’s medication regimen to rule out any modifiable migraine causes.16

The prevention of migraines in elderly patients is multifaceted. Successful prophylaxis may require trials of different medications, and

adequate dose and duration of therapy for each agent is necessary to assess effectiveness. Modifiable causes of migraine should also

be managed to prevent migraines. Next month’s newsletter will discuss acute treatment options, as well as describe pipeline agents

for preventing or treating migraines.

1. The International Classification of Headache Disorders, 3rd edition (beta version). . 2013;33(9):629-808.2. QuickStats: Percentage of Adults Aged ≥18 Years Who Reported Having a Severe Headache or Migraine in the Past 3

Months, by Sex and Age Group — National Health Interview Survey, United States, 2015.2017;66:654. DOI: http://dx.doi.org/10.15585/mmwr.mm6624a8

3. Cull RE. Investigation of late-onset migraine. 1995; 40 (2):50-2.4. Wang SJ, Liu HC, Fuh JL, Liu CY, Wang PN, Lu SR. Comorbidity of headaches and depression in the elderly. .

1999;82(3):239-43.5. Marins KM, Bordini CA, Bigal ME, et al. Migraine in the elderly: a comparison with migraine in young adults. 2006:

46(2):312-6.6. Precipe, M Caini AR, Ferretti C, et al. Prevalence of headache in an elderly population: attack frequency, disability, and use of

medication. . 2001;70:377-81.7. Ad Hoc Committee of the Italian Society for the Study of Headaches (SISC). Diagnostic and therapeutic guidelines for mi-

graine and cluster headache. 2001;2(3):105-92.8. Edmeads J, Wang SJ. Headaches in the elderly. In: Olesen J, Goadsby P, Ramadan NM, et al., editors. The headaches. 3rd ed.

Philadelphia (PA): Lippincott Williams & Wilkins, 2006: 1105-10.9. Evers S, Marziniak M. Clinical features, pathophysiology, and treatment of medication-overuse headache.

2010;9:391-401.10. De felice M, Ossipov MH, Porreca F. Update on medication-overuse headache. . 2011;15(1):79-83.11. Bravo TP. Headaches of the elderly. . 2015;15(6):30.12. Barbanti P, Aurilia C, Egeo G, Fofi L. Hypertension as a risk factor for migraine chronification. 2010;31 Suppl

1:S41-3.13. Gudmundsson LS, Thorgeirsson G, Sigfusson N, Sigvaldason H, Johannsson M. Migraine patients have lower systolic but

higher diastolic blood pressure compared with controls in a population-based study of 21,537 subjects. The Reykjavik Study. 2006;26(4):436-44.

14. Evidence based guideline update: pharmacologic treatment for episodic migraine prevention in adults. Report of the qualitystandards subcommittee of the American Academy of Neurology and The American Headache Society. .2012;78:1337-1345.

15. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.. 2015;63(11):2227-46.

16. American Medical Directors Association. Pain Management in the Long Term Care Setting Clinical Practice Guideline.Columbia, MD: AMDA 2012.

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