Experts Outline Migraine Treatment Choices for Elderly Patients

Migraine is a prevalent and burdensome disorder; although its prevalence decreases after the age of 60 years, the condition still poses a burden for older patients. A recent editorial outlined how to choose the necessary migraine pharmacotherapy for an elderly person and emphasized the importance of the careful personalization of treatment based on individual patient characteristics in order to choose a safe and effective migraine treatment.

The report noted that tricyclic antidepressants (TCAs), β-blockers (propranolol, atenolol, or metoprolol), anticonvulsants (topiramate or sodium valproate), and calcium channel blockers (cinnarizine or flunarizine) received the highest recommendation levels based on strength of scientific evidence and clinical effectiveness. For acute treatments for migraine attacks, nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol, ergotamine, triptans, and antiemetics were recommended. This high amount of drugs available increases the risk of underestimated drug-drug interactions (DDIs), according to the authors.

“A decline of organ functions and age-associated illnesses characterize the aging process. The resulting pharmacokinetic (PK) and pharmacodynamic (PD) changes are the key source of variability in the interindividual response to drugs,” explained the authors. “Drug distribution, metabolism, and elimination represent PKs alterations sensitive to aging. A decrease in body weight, hydration, muscle/fat ratio, and albumin levels affect drugs solubility and distribution.”

The authors emphasized how the clinical effect of drug hypersensitivity is revealed through the increased risk of adverse drug reactions (ADRs). The increased risk of the adverse effects must be balanced with pre-existing illness. Overall, the researchers suggested that every drug used be started at low dosages with slow titration schedules.

“Polypharmacy is prevalent in elderly patients due to comorbidities and has been associated with lower treatment adherence, quality of life and suboptimal health outcomes,” the authors stated. “Polypharmacy has been also associated with a higher prevalence of DDI-related ADRs in the geriatric population, which has already an increased risk of ADRs and ADRs-associated mortality.”

The article explained that pre-emptive identification of DDIs is one of the most important safety factors for elderly patients. Furthermore, the combination of migraine preventive and acute drugs may lead to clinically significant DDIs—affecting PK and PD profiles—and be responsible for an altered drug response, according to the editorial.

Overall, the authors concluded that there is a lack of information about the adaptation of drug prescribing for geriatric patients, which reflects the need for additional strategies for improving migraine treatment choice.

Reference

Curto M, Capi M, Martelletti P, Lionetto L. How do you choose the appropriate migraine pharmacotherapy for an elderly person [published online November 7, 2018]? Expert Opin Pharmacother. doi: 10.1080/14656566.2018.1543660.