Among migraine symptomatic drugs, the safest is paracetamol. NSAIDs may also be used, in absence of contraindications. They have however potentially severe adverse events, particularly gastroenteric and renal side effects [399
Among antiemetics domperidone should be preferred to metoclopramide which, particularly in the elderly, can be responsible for extrapyramidal side effects.
Controlled studies on the use of triptans by patients over 65 years are lacking. From the few data available in the literature, the use of triptans in a general population did not demonstrate a greater frequency of cardio- and cerebrovascular complications in patients over 65 years without vascular risk factors (1,037). In the experts’ opinion their use is therefore possible in the presence of low frequency of attacks, after a careful evaluation of cardio- and cerebrovascular risks in the single patient. Conversely, ergot derivatives are contraindicated due to their widespread vasoconstrictive action. Use of combination drugs must be limited due to the risk of abuse. The use of opioid drugs is unadvisable because of the adverse events, such as disorientation, sedation and nausea [400
First-choice drugs for prophylaxis are beta-blockers, particularly atenolol, metoprolol and bisoprolol because of their good tolerability profile [401
]. Their contraindications are chronic obstructive pulmonary disease, bradycardia or ventricular hyperkinetic arrhythmias and depression. Beta-blockers must be used with caution in presence of diabetes. The use of flunarizine should be limited because of its potential side effects with particular regard to extrapyramidal disturbance and parkinsonism.
In relation to the high prevalence of depression in the elderly, antidepressants represent a good therapeutic option [402
]. Although effective, tricyclic antidepressants (amitriptyline, nortriptyline) are not free from adverse events, which may be even severe, particularly in the elderly. They include sedation, cognitive disturbances, cardiac rhythm disturbances (tachycardia, hyperkinetic arrhythmias), postural hypotension, acute glaucoma and urinary retention, particularly in patients with prostatic hypertrophy [403
SSRI and SNRI are better tolerated but they have not shown a significant efficacy for migraine prophylaxis in randomized controlled studies. Their usefulness must be evaluated in individual cases.
The use of antiepileptics should be limited to migraine with a high frequency of attacks and in the case of comorbidity of migraine with epilepsy. Topiramate and sodium valproate should be preferred based on the greater availability of data showing efficacy, but they are not free from adverse events. In particular, topiramate may induce cognitive disturbances and sedation and, rarely, is responsible for visual disturbances (acute myopia onset, glaucoma) and nephrolithiasis. Topiramate use is contraindicated in the last two disturbances [403
Sodium valproate, conversely, may cause tremors, ataxia and hepatotoxicity (particularly in patients with previous hepatic disturbances). Other antiepileptics with lesser evidence of efficacy, but a higher tolerability profile can be alternatively used, such as gabapentin and, in some cases, pregabalin [401
Given the recent evidence of efficacy of lisinopril and candesartan in migraine prophylaxis, their use can be considered because of the good tolerability profile especially in the presence of hypertension.
There are no studies regarding the treatment of tension-type headache in elderly patients. Paracetamol and NSAIDs are recommended for symptomatic treatment, keeping in mind the considerations already reported for migraine.
Given the frequent comorbidity with depressive disturbances, antidepressants are the first-choice drugs among preventive drugs. Mirtazapine, SSRI (fluoxetine, paroxetine, fluvoxamine, sertraline, citalopram and escitalopram) or SNRI (venlafaxine, duloxetine) should be preferred because of their greater tolerability profile in comparison with tricyclics, even if controlled and randomized studies of elderly tension-type headache are lacking.
Drugs with fewer evidence of efficacy are tizanidine and onabotulinumtoxinA for which, in the literature, data are contrasting and, in the majority of cases, negative.
Non-pharmacological procedures are often the only applicable treatments although there is no evidence of their efficacy in geriatric patients. It should be emphasized that the psychiatric approach, if needed, is particularly difficult in elderly patient.
Sumatriptan s.c. is not recommended because of the limitation in its use by patients over 65 years of age and for the possible occurrence of angina and hypertensive crises. The first-choice drug is oxygen 100 %, by inhalation using a mask, at the rate of 7 l/min for 15 min. For preventive treatment the best drug for geriatric patients is verapamil which is well tolerated by patients up to a dosage of 480 mg/day. Side effects for which its suspension is recommended are rare (bradycardia, hypotension, constipation, peripheral edemas). It can be useful to associate melatonine with verapamil, at an evening dosage of 6–10 mg [402
]. In the case of an unsatisfactory response to verapamil, the second choice drug is prednisone at the dosage of 50 mg, in association with a proton-pump inhibitor. Its use should be limited to a short period (7–14 days). The use of lithium must be restricted to cases refractory to the other prophylactic treatments given the low tolerability in the elderly. The periodic plasma monitoring of lithium levels is needed and values should be maintained within the therapeutic range (0.4–1.2 mEq/l).
There are no data regarding the use of sodium valproate and topiramate by CH elderly patients in the unresponsive chronic forms.
As far as the non-pharmacological therapies are concerned, there are no data relative to the application in the elderly of new procedures such as the hypothalamic deep brain stimulation and greater occipital nerve stimulation.
With regard to the treatment of the other primary headaches in the elderly, such as hypnic headache and paroxysmal headache, one can refer to the papers recently published by our subgroups of experts on other primary headaches (2–5).