Metoprolol vs Propranolol for Migraine Prophylaxis
Propranolol is the preferred beta blocker for migraine prophylaxis over metoprolol based on substantially stronger evidence—46 controlled trials versus 14 trials—though both are effective first-line options when propranolol is contraindicated or not tolerated. 1, 2
Evidence Hierarchy
Propranolol: The Gold Standard
- Propranolol 120-240 mg daily has the most robust evidence base with 46 controlled trials demonstrating consistent efficacy for migraine prevention 1, 2
- A Cochrane systematic review of 58 trials (5,072 participants) confirmed clear short-term superiority over placebo across 26 placebo-controlled trials 3
- The American College of Physicians explicitly recommends propranolol as a first-line option before considering expensive CGRP therapies 2
Metoprolol: Effective but Less Studied
- Metoprolol has demonstrated efficacy in 14 controlled trials, making it a legitimate alternative but with a narrower evidence base 1
- Direct head-to-head trials show no significant clinical differences between metoprolol 100-200 mg daily and propranolol 80-160 mg daily in attack frequency, severity scores, or subjective improvement 4, 5
- A double-blind crossover study of 56 patients found metoprolol 50 mg twice daily clinically equivalent to propranolol 40 mg twice daily 5
Practical Prescribing Algorithm
Start with propranolol unless specific contraindications exist:
- Begin propranolol at 80 mg daily and titrate gradually to 120-240 mg daily based on response 2, 6
- Allow 2-3 months at therapeutic dosing before declaring treatment failure 7, 6
Switch to metoprolol if:
- Patient has asthma or COPD (metoprolol's beta-1 selectivity offers theoretical advantage) 5
- Propranolol causes intolerable side effects (fatigue, depression, sexual dysfunction) 2, 6
- Use metoprolol 100-200 mg daily in slow-release formulation 4
Critical Pitfall to Avoid
Never prescribe beta blockers with intrinsic sympathomimetic activity (ISA) for migraine prophylaxis—acebutolol, alprenolol, oxprenolol, and pindolol are ineffective 1, 2, 8
Side Effect Profile
Both agents share similar tolerability:
- Fatigue, depression, nausea, dizziness, and insomnia are most common 2, 6
- Dropout rates and side effect frequency were comparable in direct comparison trials 5
Why Propranolol Remains First Choice
The volume of evidence matters in clinical practice. With 46 trials versus 14 trials, propranolol's efficacy is established across diverse patient populations, dosing regimens, and outcome measures 1, 2. While metoprolol performs equivalently in head-to-head comparisons, the depth of evidence supporting propranolol provides greater confidence in real-world effectiveness 3, 8.