Metoprolol Dosing for Migraine Prophylaxis
The typical starting dose of metoprolol for migraine prophylaxis is 50 mg twice daily (100 mg total daily dose), which can be titrated up to 200 mg daily if needed. 1, 2
Dosing Guidelines
- Initial dose: 50 mg twice daily (100 mg total daily dose)
- Effective dose range: 100-200 mg daily
- Maximum dose: 200 mg daily
- Administration: Can be given as divided doses (twice daily) or as a slow-release preparation once daily
Evidence for Dosing
Multiple clinical studies have established the efficacy of metoprolol for migraine prophylaxis:
- Metoprolol at 100 mg daily has shown efficacy similar to propranolol 80 mg daily and pizotifen 1.5 mg daily 3
- At 200 mg daily (using slow-release preparation), metoprolol demonstrated significant superiority over placebo and comparable efficacy to propranolol 160 mg daily 1
- A direct comparison study showed that metoprolol 50 mg twice daily (100 mg total) was clinically equivalent to propranolol 40 mg twice daily (80 mg total) for migraine prophylaxis 2
Administration Considerations
Formulation options:
- Standard tablets: Typically divided into twice-daily dosing
- Slow-release tablets: Can be administered once daily (morning administration preferred)
Titration: Start with the lower dose (100 mg daily) and assess efficacy after 4-6 weeks before considering dose increases
Monitoring and Follow-up
- Evaluate response after 4-6 weeks of treatment
- If effective, continue treatment for at least 3-6 months before considering discontinuation
- Monitor for common beta-blocker side effects:
- Hypotension
- Bradycardia
- Fatigue
- Sleep disturbances
Important Precautions
Contraindications:
- Asthma or obstructive airway disease
- Decompensated heart failure
- Pre-excited atrial fibrillation or flutter
- Severe bradycardia
Discontinuation: When stopping treatment, gradually taper the dose over several weeks to prevent rebound symptoms
Alternative Beta-Blockers
If metoprolol is not tolerated or ineffective, other beta-blockers with established efficacy in migraine prophylaxis include:
- Propranolol: 80-240 mg daily
- Timolol: 20-30 mg daily
- Bisoprolol: 5 mg daily 4
Beta-blockers remain among the first-line preventive options for migrainous headaches, alongside topiramate and amitriptyline 5.