Propranolol vs Metoprolol for Migraine Prevention
Propranolol is the preferred medication over metoprolol for migraine prevention due to stronger evidence supporting its efficacy and its established status as a first-line agent in clinical guidelines. 1
Evidence-Based Comparison
First-Line Agents
According to established guidelines, the following medications are recommended as first-line agents for migraine prevention:
- Propranolol (80-240 mg/day)
- Timolol (20-30 mg/day)
- Amitriptyline (30-150 mg/day)
- Divalproex sodium (500-1,500 mg/day)
- Sodium valproate (800-1,500 mg/day) 1
Notably, metoprolol is not included in this first-line list, though it has shown some efficacy.
Beta-Blockers Evidence
- Propranolol: Consistently strong evidence supports its efficacy at doses of 80-240 mg/day 1
- Metoprolol: Only limited evidence of moderate effect 1
- Beta-blocker selection: Among beta-blockers, propranolol has the most robust evidence base and is specifically named in guidelines as a first-line agent 1, 2
Comparative Efficacy
Direct Comparisons
While one older study found no significant difference in efficacy between metoprolol and propranolol 3, more recent guidelines consistently position propranolol as the beta-blocker of choice based on the totality of evidence.
Efficacy Against Other Agents
- A recent study (2024) found that propranolol was less effective than amitriptyline at reducing the frequency, duration, and severity of migraine attacks 4
- However, propranolol demonstrated significantly greater reduction in headache severity compared to sodium valproate in another study 5
Dosing and Administration
- Propranolol: 80-240 mg daily (divided doses)
- Start with a low dose and gradually increase until benefits are achieved without adverse effects
- Clinical benefits may take 2-3 months to become apparent 1
Adverse Effects
Common side effects of beta-blockers including propranolol:
- Fatigue
- Depression
- Nausea
- Dizziness
- Insomnia
These symptoms are generally well-tolerated and rarely cause patients to discontinue treatment 1.
Special Considerations
Patient-Specific Factors
- Migraine type: Propranolol appears more efficacious in patients with migraine alone, while amitriptyline may be superior for patients with mixed migraine and tension-type headache 1
- Contraindications: Avoid beta-blockers in patients with asthma, severe bradycardia, heart block, or heart failure
Important Clinical Caveat
Beta-blockers with intrinsic sympathomimetic activity (acebutolol, alprenolol, oxprenolol, pindolol) are ineffective for migraine prevention and should be avoided 1.
Treatment Algorithm
- Evaluate patient for migraine prevention therapy (if ≥2 attacks/month with ≥3 days disability/month, medication overuse, or uncommon migraine conditions)
- Select propranolol as first-line beta-blocker option (80-240 mg/day)
- Start at low dose and gradually increase over 2-4 weeks
- Assess efficacy after 2-3 months of treatment
- If inadequate response or intolerable side effects, consider switching to another first-line agent (timolol, amitriptyline, divalproex sodium, or sodium valproate)