What are the preferred beta blockers (beta-adrenergic blocking agents) for migraine prophylaxis?

Preferred Beta Blockers for Migraine Prophylaxis

Propranolol (120-240 mg daily) and metoprolol are the preferred beta blockers for migraine prophylaxis, with propranolol having the strongest evidence base from 46 controlled trials. 1

First-Line Beta Blocker Selection

Propranolol should be your initial beta blocker choice for the following reasons:

• Propranolol 120-240 mg daily has consistent evidence for efficacy from 46 controlled trials, making it the most extensively studied beta blocker for migraine prevention 1
• The FDA specifically approves propranolol for migraine prophylaxis 2
• Propranolol demonstrated effectiveness in reducing headache unit index (composite of frequency and severity) in a 34-week placebo-controlled trial 2
• Optimal dosing ranges from 160-240 mg daily based on clinical experience, though many patients receive suboptimal doses 3

Metoprolol is an equally valid first-line alternative:

• Metoprolol has been studied in 14 controlled trials with evidence of efficacy 1
• The 2025 American College of Physicians guideline specifically recommends either metoprolol or propranolol as first-line options before considering more expensive CGRP therapies 1
• Metoprolol may be preferred in patients who cannot tolerate propranolol's side effects 4

Other Effective Beta Blockers (Second-Tier Options)

Timolol 20-30 mg daily has good evidence for efficacy and is FDA-approved for migraine prevention, though less extensively studied than propranolol 1, 4

Nadolol and atenolol have limited but supportive evidence for moderate efficacy:

• Nadolol has been shown effective in controlled trials 1, 5
• Atenolol has limited evidence from fewer studies 1, 4

Critical Pitfall: Avoid Beta Blockers with Intrinsic Sympathomimetic Activity

Never use beta blockers with intrinsic sympathomimetic activity (ISA) for migraine prophylaxis - they are ineffective:

• Acebutolol, alprenolol, oxprenolol, and pindolol have been shown to be ineffective for migraine prevention 1
• The absence of ISA is the only beta blocker property negatively correlated with migraine efficacy 5, 6

Practical Dosing Algorithm

Start propranolol at lower doses and titrate upward:

1. Begin with 80 mg daily (divided doses or extended-release)
2. Increase gradually to 120-240 mg daily based on response 1, 2
3. Allow at least 4 weeks to assess efficacy, though improvement may continue over time 4
4. Suboptimal dosing is common in practice - ensure adequate dose before declaring treatment failure 3

Common Side Effects to Monitor

Expect and counsel patients about:

• Fatigue, depression, nausea, dizziness, and insomnia are most common 1
• These symptoms are generally well-tolerated and rarely cause treatment discontinuation 1
• Beta blockers may be more effective than amitriptyline in patients with pure migraine (without tension-type headache) 1

Position in Treatment Algorithm

Use propranolol or metoprolol as first-line prophylaxis before considering:

• CGRP monoclonal antibodies or gepants (substantially more expensive at $7,071-$22,790 annually) 1
• Topiramate (higher adverse event frequency, use only after beta blocker failure) 1
• Consider beta blockers alongside valproate, venlafaxine, or amitriptyline as equivalent first-line options based on patient-specific factors 1