Which is more effective for headache prevention, metoprolol (beta blocker) or propranolol (beta blocker)?

Propranolol is More Effective Than Metoprolol for Headache Prevention

Based on the most recent and highest quality evidence, propranolol is more effective than metoprolol for headache prevention, with consistent evidence supporting its efficacy in preventing migraine attacks. 1, 2

Evidence Comparison

Beta-Blockers for Migraine Prevention

• The American Academy of Family Physicians recommends beta-blockers as first-line preventives for migraine, specifically highlighting propranolol (80-240mg/day) 2
• Propranolol has been investigated in 46 studies compared to only 14 studies for metoprolol, demonstrating more robust evidence for propranolol 1
• The US Headache Consortium found consistent evidence for the efficacy of propranolol at doses of 120-240mg daily in preventing migraine attacks 1

Comparative Effectiveness

• In a direct comparison study using time-series analysis, propranolol and metoprolol showed different response rates:
  • Metoprolol showed significant improvement in 54.4% of migraine patients
  • Propranolol showed reduction in migraine attack frequency in only 32% of patients 3
• However, analysis of variance failed to show any statistically significant difference between the responder rates for metoprolol and propranolol 3
• The American Academy of Neurology and Canadian Headache Society both include propranolol in their strong recommendations for migraine prevention 4

Dosing Considerations

• Propranolol dosage:

  • Effective dose range: 80-240mg/day 2
  • Low doses (approximately 1mg/kg body weight daily) can be effective in many patients (73.5% in one study) 5
  • Higher doses tend to be more effective but may cause more side effects 3

• Metoprolol dosage:

  • Not specifically mentioned in the most recent guidelines, but historically used at similar doses to other beta-blockers

Clinical Application Algorithm

1. Initial Selection:

   • Choose propranolol as first-line beta-blocker for headache prevention based on stronger evidence base
   • Start with low dose (approximately 1mg/kg/day) to minimize side effects

2. Dose Titration:

   • Begin with 20-40mg twice daily
   • If no response after 4 weeks, gradually increase to 120-240mg daily (divided doses)
   • Monitor for side effects (fatigue, hypotension, bradycardia)

3. Evaluation of Efficacy:

   • Assess response after 2-3 months of treatment 2
   • Use headache diary to track frequency, intensity, and duration

4. Alternative Considerations:

   • If propranolol is contraindicated or poorly tolerated, consider other first-line preventives:
     • Amitriptyline (30-150mg/day)
     • Topiramate (100mg/day)
     • Divalproex sodium (500-1500mg/day)

Important Caveats

• Beta-blockers with intrinsic sympathomimetic activity are ineffective for preventing migraine 1
• Contraindications to beta-blockers include asthma, heart block, and severe bradycardia
• Consider preventive treatment if migraines occur ≥2 days per month with significant impact despite optimized acute treatment 2
• Treatment duration should be at least 3-4 months to reach maximal efficacy 2
• Medication overuse (use of simple analgesics >15 days/month or triptans/combination analgesics >10 days/month) should be identified and addressed 2

While both propranolol and metoprolol are effective for headache prevention, the weight of evidence and guideline recommendations favor propranolol as the more effective beta-blocker option based on the extensive research supporting its use.