Which antihypertensive (blood pressure lowering) medications help with migraines?

Beta-Blockers Are the Most Effective Antihypertensives for Migraine Prevention

Beta-blockers, particularly propranolol and timolol, are the most effective antihypertensive medications for migraine prevention, with strong evidence supporting their efficacy. 1

First-Line Beta-Blockers for Migraine Prevention

• Propranolol (80-240 mg daily) and timolol (20-30 mg daily) have the strongest evidence for efficacy in migraine prevention and are FDA-approved for this indication 1
• Metoprolol (100-200 mg daily) also has good evidence for migraine prevention and is commonly used off-label 1, 2
• These beta-blockers reduce migraine frequency, severity, and associated symptoms, improving quality of life 1, 3
• Beta-blockers without intrinsic sympathomimetic activity (ISA) are effective, while those with ISA (acebutolol, alprenolol, oxprenolol, pindolol) are ineffective for migraine prevention 1

Other Beta-Blockers with Evidence for Migraine Prevention

• Atenolol and nadolol have limited but positive evidence for moderate effectiveness in migraine prevention 1, 4
• Nebivolol has shown promising results in comparative studies with metoprolol, with similar efficacy but better tolerability 5
• Bisoprolol has limited evidence but may be effective in some patients 2

Other Antihypertensive Classes for Migraine Prevention

• Calcium channel blockers: Verapamil has moderate evidence for efficacy, though less consistent than beta-blockers 1
• Angiotensin II receptor blockers: Candesartan has shown efficacy in reducing monthly headache days 3, 2
• Angiotensin-converting enzyme inhibitors: Lisinopril has limited evidence but may be beneficial 4, 2
• Alpha-blockers: Some evidence for clonidine, though generally less effective than other options 3

Selecting the Appropriate Agent

• Consider beta-blockers as first-line therapy when treating a patient with both hypertension and migraine 1, 6
• For patients with both migraine and hypertension, target doses for optimal effect are higher than those often prescribed (e.g., metoprolol 200 mg daily, not 25 mg BID) 6
• Avoid beta-blockers with intrinsic sympathomimetic activity as they are ineffective for migraine prevention 1
• Avoid atenolol for hypertension management as it is less effective than placebo in reducing cardiovascular events, despite some efficacy in migraine 1

Common Side Effects and Contraindications

• Common side effects of beta-blockers include fatigue, dizziness, nausea, depression, and insomnia, but these are generally well-tolerated 1
• Beta-blockers should be used cautiously in patients with asthma, diabetes, or peripheral vascular disease 1
• Start with low doses and titrate gradually to minimize side effects while achieving therapeutic benefits 1

Treatment Duration and Expectations

• An adequate trial requires 2-3 months to determine efficacy, as benefits may not be immediately apparent 1, 6
• After 6-12 months of successful treatment, consider tapering to find the minimum effective dose or discontinue 1
• Prophylactic treatment is indicated for patients with two or more migraine attacks per month, attacks producing disability for three or more days per month, or use of acute medications more than twice weekly 1, 7

Non-Antihypertensive Options for Migraine Prevention

• Anticonvulsants: Divalproex sodium, sodium valproate, and topiramate have strong evidence for efficacy 1, 2
• Antidepressants: Amitriptyline has consistent evidence for efficacy, especially in patients with mixed migraine and tension-type headache 1
• These non-antihypertensive options should be considered when beta-blockers are contraindicated or ineffective 1

Beta-blockers remain the cornerstone of treatment for patients with both hypertension and migraine, with propranolol and timolol having the strongest evidence base. When selecting an antihypertensive for a patient with migraines, these agents should be prioritized for their dual benefit.