Beta‑Blocker Selection for Migraine Prophylaxis

First‑Line Agents with Strong Evidence

Propranolol (80–240 mg/day) is the most extensively studied beta‑blocker and is recommended as a first‑line preventive medication for migraine by the U.S. Headache Consortium and the American Academy of Family Physicians/ACP‑ASIM, based on multiple high‑quality trials demonstrating consistent efficacy【1】【2】【3】.
Timolol (20–30 mg/day) also has solid evidence supporting its use as a first‑line agent and is endorsed by the same guideline bodies【4】【5】【6】.

Metoprolol, atenolol, and nadolol show moderate effectiveness for migraine prevention but are supported by limited evidence; they may be considered when propranolol or timolol are contraindicated or not tolerated【1】【2】【3】.

Beta‑blockers with intrinsic sympathomimetic activity (acebutolol, alprenolol, oxprenolol, pindolol) are ineffective for migraine prophylaxis and should not be used【1】【2】【3】.

Propranolol is superior in patients with migraine alone (without co‑existing tension‑type headache)【4】【1】【2】.
When migraine co‑exists with tension‑type headache, amitriptyline is suggested as an alternative【4】【5】.

Initiate therapy at a low dose and titrate slowly, increasing until clinical benefit appears or adverse effects limit further escalation【4】【5】.
Allow an adequate trial period of 2–3 months, as therapeutic effects may not become evident earlier【4】【5】.

Common adverse effects include fatigue, depression, nausea, dizziness, and insomnia; these are generally well tolerated and rarely lead to premature discontinuation【4】【1】【2】.
Contraindications: avoid beta‑blockers in patients with asthma, severe bradycardia, heart block, or uncontrolled heart failure【6】.

CGRP‑targeted monoclonal antibodies (erenumab, fremanezumab, galcanezumab) have strong evidence for episodic and chronic migraine prevention【7】.
Despite newer agents, propranolol and timolol remain first‑line options because of their established efficacy, favorable safety profile, and cost‑effectiveness【4】【6】.

The 2025 American College of Physicians (ACP) guidelines continue to endorse beta‑blockers as appropriate first‑line preventive therapy for migraine【8】.