In elderly patients, which preventive migraine medication is generally favored due to a safer cognitive profile?

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In elderly patients, the choice of preventive migraine therapy is guided by cognitive safety. Medications with minimal impact on thinking, memory, and alertness are preferred to reduce the risk of cognitive decline or delirium. Beta-blockers, particularly metoprolol, tend to have fewer cognitive side effects and are generally well tolerated in older adults, making them a safer option for this aspect of care. In contrast, topiramate can cause cognitive slowing and memory problems; amitriptyline has anticholinergic effects that can worsen cognition and cause sedation; NSAIDs carry other systemic risks (gastrointestinal, renal, cardiovascular) that are especially concerning in the elderly. Thus, metoprolol stands out for offering migraine prevention with a safer cognitive profile.