What is the recommended dose of atenolol (beta-blocker) for migraine prevention?

Atenolol Dosing for Migraine Prevention

For migraine prevention, atenolol should be used at a dose of 50 mg once daily, which has been shown to be effective in reducing both frequency and severity of chronic migraine attacks. 1

Recommended Beta-Blockers for Migraine Prevention

• Propranolol (80-240 mg/day) and timolol (20-30 mg/day) are the beta-blockers with the strongest evidence for migraine prevention and are considered first-line agents 2, 3
• Atenolol (50 mg/day) has demonstrated efficacy in reducing migraine frequency from 20.1 to 7.1 days per month and severity from 2.3 to 1.4 in intensity after 3 months of treatment 1
• Beta-blockers without intrinsic sympathomimetic activity (ISA) are effective for migraine prevention, while those with ISA should be avoided 4

Dosing and Administration Guidelines

• Start with a low dose of atenolol (50 mg daily) and assess response after 1.5 months 1
• Significant improvement can be seen as early as 1.5 months of treatment, with continued improvement through 3 months 1
• An adequate trial requires 2-3 months as clinical benefits may not become apparent immediately 3
• If using propranolol instead, start with a low dose and gradually increase to 80-240 mg daily as needed and tolerated 3, 5

Efficacy and Patient Selection

• Consider beta-blockers for patients with:

  • Two or more migraine attacks per month with disability lasting 3+ days per month 3
  • Use of acute rescue medications more than twice per week 3
  • Failure of or contraindications to acute migraine treatments 3

• In one study, 29% of patients with chronic migraine became completely headache-free after 3 months of atenolol treatment 1

• Propranolol appears more effective for pure migraine, while amitriptyline may be superior for mixed migraine and tension-type headache 3

Side Effects and Monitoring

• Common adverse effects of beta-blockers include:

  • Fatigue, depression, nausea, dizziness, and insomnia 2, 3
  • These side effects are generally well-tolerated 2

• Monitor for:

  • Mood changes, particularly depression 3
  • Sleep disturbances 3
  • Bradycardia or heart block (contraindications) 3

Alternative First-Line Options

• Other first-line agents for migraine prevention include:

  • Amitriptyline (30-150 mg/day) 2, 3
  • Divalproex sodium (500-1,500 mg/day) 2
  • Sodium valproate (800-1,500 mg/day) 2
  • Candesartan or telmisartan (ARBs) are strongly recommended by newer guidelines 2

• For patients who fail to respond to beta-blockers, newer options include:

  • CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) which are strongly recommended for both episodic and chronic migraine 2
  • Topiramate, which has a weak recommendation for both episodic and chronic migraine 2

Treatment Duration

• After achieving a period of stability (usually 2-3 months), consideration can be given to tapering or discontinuing the medication 2
• Continuous assessment of efficacy and side effects is recommended throughout treatment 3