Migraine in Older Adults

Medically reviewed by: Nina Riggins MD, PhD, FAAN, FAHS, UCNS

Diagnosing and treating headache disorders in older adults can be complex due to various factors. Migraine, which affects about 10% of older adults, can be particularly challenging to manage.¹ Underlying health conditions can affect treatment choices, and symptoms may change or new ones may develop. Also, there is a higher potential for headaches to occur from secondary causes which may require emergency diagnosis and treatment.

What are Secondary Headaches?

People in their 60s or older who have new-onset headache symptoms or significant changes in existing headache symptoms should see a healthcare provider immediately. It is not unheard of for older adults to develop new-onset migraine but other causes should be excluded by a health care provider. Older adults are at higher risk for developing secondary headache, or headache with an underlying cause—including conditions that need emergency treatment, like stroke, heart attack or giant cell arteritis.¹ Many other sources of secondary headache, like sleep apnea or post-herpetic neuralgia (neuralgia that occurs after a case of shingles), may not need emergency response but do require timely diagnosis and treatment to avoid more serious complications.¹

How May Migraine Present in Older Adults?

Once a secondary headache has been ruled out, a provider may assess any changes in migraine symptoms. Older people may experience pain on both sides of their head, rather than one side, with less sensitivity to light and sound.^1,2 The attacks may occur more at night or in the early morning.^1,2 They are also more likely to develop new visual aura symptoms, frequently without the accompanying head pain.^1,2 These aura symptoms may mimic stroke or transient ischemic attack (TIA), so it’s important to get them properly diagnosed immediately.^1,2

Treatment Considerations for Older Adults

Aging increases the risk of various health issues, medication interactions and sensitivities, as well as the presence of other chronic conditions. Changes in kidney and liver function can affect how drugs are processed and eliminated from the body. Onset of new chronic conditions like heart disease, kidney disease, and osteoporosis can impact the treatment options a provider may prescribe, even for those who have used the treatments safely for years or decades. Depending on the pre-existing conditions and risk factors, certain treatments are often avoided for older adults.

What to consider when choosing acute treatments for migraine?

• Triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan): May constrict blood vessels and are often avoided for people with high blood pressure, cardiovascular disease or a history of stroke.
• Ergotamine derivatives (dihydroergotamine, ergotamine): May constrict blood vessels and are often avoided for people with cardiovascular disease. 
• NSAIDS (naproxen, ibuprofen): May increase risk of gastrointestinal bleeding and kidney issues. Often avoided in people who use anticoagulant medications. 
• Acetaminophen and combination medications (aspirin, acetaminophen and caffeine): May increase liver enzymes, additional monitoring may be needed.
• Opioids and barbiturates (morphine, butalbital): May cause sedation and confusion in older adults. They are typically not recommended for acute migraine treatment but may be considered if other treatments are ineffective.

What to consider when choosing preventive treatments for migraine?

• Beta blockers (propranolol, metoprolol): May lower heart rate, cause dizziness or low blood pressure and exacerbate respiratory conditions or glaucoma.
• Anti-seizure medications (topiramate, valproic acid)
  • Topiramate: May cause cognitive or memory impairment, kidney stones and glaucoma. 
  • Valproic acid: May cause an increase in liver enzymes, changes in levels of other medications that a person takes and weight gain. 
• Tricyclic antidepressants (amitriptyline, nortriptyline): May cause sedation, orthostatic hypotension, changes in heart rhythm and anticholinergic effects (dry mouth, urinary retention, blurred vision, etc.)

*This is a general list of treatment options that should be avoided for older adults; however, they may be safe for some individuals. Please consult your doctor.*

Safer Treatment Options for Older Adults

The good news is that there are many treatment options available for older adults.

Acute treatments

• Ditans (lasmiditan): Oral medication that works on one specific serotonin receptor responsible for headache found on nerves but not on blood vessels. Caution also should be used as lasmiditan can cause dizziness and has a warning to avoid driving for 8 hours after intake.
• Gepants (rimegepant, zavegepant, ubrogepant): Rimegepant and ubrogepant are oral treatments while zavegepant is a nasal spray. All three treatments target a protein called CGRP which is involved in the migraine attack process.
• Neuromodulation devices (Nerivio, Cefaly, Relivion, gammaCore, SAVI Dual): These devices deliver electrical or magnetic impulses to reduce, eliminate or prevent migraine attacks. They are worn or held against different parts of the body to modulate nerves or areas of the brain and nervous system involved in the migraine process.
• Nerve blocks: A peripheral nerve block is administered by a clinician who injects a small amount of local anesthetic, or numbing solution, such as lidocaine or bupivacaine, around a specific nerve for pain relief. They can work quickly but may also provide relief for days to weeks to months.

Preventive treatments

• Vitamins and supplements (magnesium, riboflavin, coenzymeQ10): Certain vitamins and supplements may reduce the frequency, severity and disability of migraine attacks.
• Candesartan: A type of blood pressure medication that is often used to preventively treat migraine.
• Gepants (atogepant, rimegepant): Oral treatments that target a protein called CGRP which is involved in the migraine attack process.
• CGRP Monoclonal Antibodies (eptinezumab, fremanezumab, galcanezumab, erenumab): Injectable or intravenous treatment that binds to CGRP or its receptors. May be used in people over 65 but that age range is often excluded from clinical trials. Erenumab may cause increased blood pressure and constipation. In general, CGRP monoclonal antibodies are not known to interact with other treatments.
• Neuromodulation devices (Nerivio, Cefaly, gammaCore, SAVI Dual, HeadaTerm 2): These devices deliver electrical or magnetic impulses to reduce, eliminate or prevent migraine attacks. They are worn or held against different parts of the body to stimulate nerves or areas of the brain and nervous system involved in the migraine process.
• Nerve blocks: A peripheral nerve block is administered by a clinician who injects a small amount of local anesthetic, or numbing solution, such as lidocaine or bupivacaine, around a specific nerve for pain relief. They can work quickly but may also provide relief for days to weeks to months.
• Memantine: Used to treat the symptoms of Alzheimer’s disease but may be effective for migraine treatment.³
• OnabotulinumtoxinA: FDA approved for chronic migraine in adults. Treatment consists of 31 injections of onabotulinumtoxinA into key muscle areas of the head and neck.
• Cognitive behavioral therapy: Addresses the way thoughts (cognitions) reciprocally interact with our actions (behaviors).

*This is a general list of treatment options that may be safer for older adults, however, they should be avoided by certain individuals. Please consult your doctor before starting or stopping any treatment.*

To prevent medication overuse headache, limit acute medication use to no more than twice per week. This type of headache can develop in people with pre-existing headache disorders, such as migraine or tension-type headaches, if they use certain acute medications (like triptans, ergotamine, NSAIDs, or combination medications) more than 10-15 times per month, depending on the medication. Unlike many other acute treatments, gepants and neuromodulation devices are not known to cause medication overuse headache. Like people of any age with a headache disorder, older adults are at risk for developing medication overuse headache. In fact, one study found that about 30% of people over 64 years old who go to a headache clinic had probable medication overuse headache.⁴

Older adults may take simple analgesics like NSAIDS and acetaminophen for other aches and pains unrelated to migraine. Even though the medication is being used for another condition, it can still contribute to medication overuse headache. It is important to always report the use of all over the counter and prescription medications to your provider, especially NSAIDS like ibuprofen or naproxen, acetaminophen and/or medications that combine aspirin, acetaminophen and caffeine.

How Aging Affects Treatments and Navigating New Sensitivities

As you age, the way certain medications affect you can change. Medications that never made you feel sleepy before may now have you craving a two-hour nap; others may affect your balance, make you feel agitated or anxious, or cause cognitive impairment.

In addition, certain migraine treatments may be contraindicated for their potential interactions with treatments for other medical conditions. These reactions may make driving, walking, household chores, and other normal daily life activities challenging. As a person ages, it is extremely important to report their medical history, emergency room visits or new onset symptoms to their general practitioner and/or neurologist or headache specialist.

However, there may be an upside to age-related medication sensitivity. Medications that had intolerable side effects when you were younger may now be tolerable and effective for you at lower doses. This isn’t universal, as some medications commonly prescribed for migraine prevention may cause side effects in older patients that are seldom seen in younger patients, but experts say some older patients have success with these treatment “sequels.”

Conclusion

Migraine in older adults often presents challenges that affect the way the disease is managed. It is important to talk to your healthcare provider as your symptoms and health history change. They can recommend modifications to your treatment plan to safely and more effectively treat your condition.

References

1. www.ncbi.nlm.nih.gov/pmc/articles/PMC9007780/
2. americanheadachesociety.org/wp-content/uploads/2021/04/AHS-First-Contact-Migraine-in-the-Elderly.pdf
3. www.ncbi.nlm.nih.gov/pmc/articles/PMC6613428/
4. pubmed.ncbi.nlm.nih.gov/29235107/

Authors

Lisa had migraine attacks for most of her adult life before being diagnosed with migraine disease. A communications strategist, writer, and former radio announcer, she lives in the Boston area, where she advocates for her fellow migraine patients every chance she gets.

Kylie Petrarca is a Registered Nurse and has experience in both medical-surgical nursing and critical care. Her passion for patient care led her to a new role in 2021 as the Education Program Director for the Association of Migraine Disorders. Kylie also lives with chronic migraine and has earned her Master of Headache Disorders from the University of Copenhagen.