Migraine Prevention with Beta-Blockers

Recommended Beta-Blockers and Dosing

The American Academy of Family Physicians recommends propranolol (80-240 mg/day) and timolol (20-30 mg/day) as first-line agents for migraine prevention, with the strongest evidence for efficacy 1, 2
Beta-blockers without intrinsic sympathomimetic activity (ISA) are considered effective for migraine prevention 1
The American Family Physician suggests that amitriptyline (30-150 mg/day) is also a first-line option for migraine prevention 1, 2

Patients with two or more migraine attacks per month with disability lasting 3+ days per month may benefit from beta-blockers 2
Patients using acute rescue medications more than twice per week may also benefit from beta-blockers 2
The American Family Physician recommends considering beta-blockers for patients with failure of or contraindications to acute migraine treatments 2

Common adverse effects of beta-blockers include fatigue, depression, nausea, dizziness, and insomnia, which are generally well-tolerated 1, 2
Monitoring for mood changes, particularly depression, sleep disturbances, and bradycardia or heart block (contraindications) is recommended 2

The American Family Physician recommends divalproex sodium (500-1,500 mg/day) and sodium valproate (800-1,500 mg/day) as alternative first-line options for migraine prevention 1
Candesartan or telmisartan (ARBs) are strongly recommended by newer guidelines for migraine prevention 3
CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) are strongly recommended for both episodic and chronic migraine, while topiramate has a weak recommendation 3

The American Academy of Family Physicians recommends continuous assessment of efficacy and side effects throughout treatment, and consideration can be given to tapering or discontinuing the medication after achieving a period of stability (usually 2-3 months) 1, 2