Can propranolol (beta-blocker) cause burning sensation in the eyes and headaches?

Can Propranolol Cause Burning Sensation in the Eyes and Headaches?

Yes, propranolol can cause both burning sensation in the eyes (through reduced tear production) and headaches, though headaches are paradoxical since propranolol is primarily used to prevent migraines.

Eye-Related Side Effects

Reduced Tear Production and Ocular Discomfort

• Oral propranolol significantly reduces tear secretion, which can manifest as burning, dryness, or irritation of the eyes 1
• This effect occurs because beta-blockers decrease aqueous humor production and tear secretion when administered systemically 2
• The reduction in tear production is a documented side effect across multiple beta-blockers, including propranolol, and was demonstrated in a study of 194 patients compared to 185 controls 1

Clinical Context

• While topical beta-blockers like timolol are used to treat glaucoma by reducing intraocular pressure, systemic propranolol can have similar ocular effects that may be beneficial for glaucoma patients but problematic for others 2
• The burning sensation likely results from inadequate tear film coverage of the corneal surface due to reduced tear production 1

Headache as a Side Effect

Paradoxical Headache Occurrence

• Propranolol can paradoxically cause headaches in some patients, despite being a first-line preventive medication for migraine 2
• A documented case report describes a 70-year-old woman who developed migrainous headaches 3 days after starting propranolol, with recurrence upon rechallenge, confirming propranolol as the causative agent 3
• This represents an uncommon but recognized adverse reaction where the drug intended to prevent headaches actually triggers them 3

Mechanism and Frequency

• The mechanism for propranolol-induced headaches is not fully elucidated but may relate to individual vascular reactivity or CNS effects 3
• While propranolol is effective for migraine prevention in 70% or more of patients at doses of 120-240 mg daily, a subset of patients experience worsening or new-onset headaches 2, 4

Other Relevant Side Effects

Common Systemic Effects

• Sleep disturbances occur in 2-18.5% of patients, including nightmares, night terrors, and agitation 5, 6
• Bradycardia, hypotension, fatigue, and cold extremities are well-documented side effects 5, 6
• CNS effects include potential impairments in memory, psychomotor function, and mood 5

Hypersensitivity Reactions

• Extremely rare immediate hypersensitivity reactions can occur, manifesting as generalized urticaria within 30 minutes of administration 7
• If true allergy is suspected, alternative beta-blockers like bisoprolol (a second-generation agent) may be tolerated 7

Clinical Management Recommendations

When Eye Burning Occurs

• Consider artificial tears or lubricating eye drops to compensate for reduced tear production 1
• If symptoms are severe or intolerable, discuss alternative beta-blockers or different drug classes for the underlying indication 2
• Avoid combining systemic propranolol with topical beta-blocker eye drops, as this increases the risk of systemic side effects including bradycardia 2

When Headaches Develop

• Distinguish between breakthrough migraines (treatment failure) and propranolol-induced headaches by temporal relationship to drug initiation 3
• If headaches worsen or newly appear after starting propranolol, consider discontinuation and rechallenge to confirm causality 3
• Alternative migraine preventive medications include topiramate, valproate, candesartan, or CGRP antagonists (erenumab, fremanezumab, galcanezumab) 2

Important Precautions

• Do not abruptly discontinue propranolol after regular use, as rebound symptoms can occur 5, 6
• Exercise caution in patients with diabetes, as propranolol may mask hypoglycemia symptoms 2, 5, 6
• Propranolol is contraindicated in asthma, COPD, bradycardia, heart block, and decompensated heart failure 6