Can atenolol (beta-blocker) be used to prevent migraines?

Atenolol for Migraine Prevention

Atenolol is an effective option for migraine prevention, though it is not among the first-line beta-blockers recommended by current guidelines. 1

Beta-Blockers for Migraine Prevention

According to the American Academy of Neurology and American Academy of Family Physicians guidelines, beta-blockers are effective first-line agents for migraine prevention 1. However, the specific beta-blockers with the strongest evidence are:

• Propranolol (80-240 mg/day)
• Timolol (20-30 mg/day)
• Metoprolol

These medications have strong, consistent evidence supporting their efficacy for migraine prevention 1.

Evidence for Atenolol

While atenolol is not specifically listed among the first-line beta-blockers in current guidelines, there is some evidence supporting its use:

• A 2013 open-label study showed that atenolol 50 mg once daily reduced mean headache days from 20.1 to 7.1 per month after 3 months of treatment in patients with chronic migraine 2
• In this study, 29% of patients experienced complete resolution of chronic migraine during the third month of treatment 2
• Older literature (1992) indicates that atenolol is among five beta-blockers (along with propranolol, metoprolol, timolol, and nadolol) that have demonstrated effectiveness as prophylactic treatment for migraine 3

Clinical Decision-Making Algorithm

1. First-line beta-blockers: Start with propranolol, timolol, or metoprolol as they have the strongest evidence base 1, 4
2. Consider atenolol when:
   • Patient has intolerance to first-line beta-blockers
   • Drug interactions or contraindications exist for first-line agents
   • Patient has comorbid conditions that might benefit from atenolol (e.g., hypertension)
3. Dosing: Start with atenolol 50 mg daily, which has shown efficacy in research 2
4. Duration of trial: Evaluate effectiveness after at least 6-8 weeks, with optimal assessment at 3 months 1

Other First-Line Preventive Options

If beta-blockers are not suitable, other first-line preventive treatments include:

• Amitriptyline (30-150 mg/day)
• Divalproex sodium (500-1500 mg/day)
• Sodium valproate (800-1500 mg/day)
• Topiramate (100 mg/day) 1

Important Considerations

• Beta-blockers without intrinsic sympathomimetic activity (like atenolol) appear to be more effective for migraine prevention 3
• Preventive treatment should be considered when migraines occur ≥2 days per month with significant impact despite optimized acute treatment 1
• A trial period of 2-3 months is recommended to properly assess efficacy of preventive treatments 1
• Monitor for common beta-blocker side effects including fatigue, dizziness, and bradycardia

Pitfalls to Avoid

• Don't abandon treatment too early; beta-blockers may take up to 3 months to show maximal efficacy 1
• Don't neglect to address lifestyle factors that can trigger migraines (sleep schedule, meal timing, hydration, stress management) 1
• Don't continue ineffective preventive treatment beyond 3-4 months without reassessment 1
• Avoid using beta-blockers in patients with asthma, severe bradycardia, or heart block

While atenolol shows promise for migraine prevention, the current evidence and guidelines more strongly support propranolol, timolol, and metoprolol as first-line beta-blocker options 1, 4.