Is propranolol (a beta blocker) effective for treating headaches?

From the Guidelines

Propranolol is suggested for the prevention of migraine, as indicated by the most recent clinical practice guideline from 2024 1.

Key Points to Consider

• The guideline suggests propranolol for migraine prevention, although the recommendation is weak due to the availability of stronger evidence for other treatments like candesartan, telmisartan, erenumab, fremanezumab, and galcanezumab 1.
• Propranolol's efficacy in migraine prevention is supported by earlier studies, with dosages ranging from 80 to 240 mg/d 1.
• It's crucial to consider the patient's overall health, potential side effects, and the presence of other conditions such as asthma, diabetes, or heart conditions before prescribing propranolol.
• Treatment should continue for at least 2-3 months to properly evaluate its effectiveness, and it should not be stopped abruptly to avoid rebound symptoms.

Important Considerations for Use

• Propranolol works by blocking beta-adrenergic receptors, which helps in reducing blood vessel dilation and inflammation contributing to migraine pain, and it also stabilizes serotonin levels in the brain 1.
• Common side effects include fatigue, dizziness, and lowered blood pressure, necessitating cautious use in certain patient populations.
• While propranolol is primarily used for migraine prevention, it may be less effective for other types of headaches, such as tension-type or cluster headaches, which might require alternative treatments.

From the FDA Drug Label

Migraine: In a 34-week, placebo-controlled, 4-period, dose-finding crossover study with a double-blind randomized treatment sequence, 62 patients with migraine received propranolol 20 to 80 mg 3 or 4 times daily The headache unit index, a composite of the number of days with headache and the associated severity of the headache, was significantly reduced for patients receiving propranolol as compared to those on placebo Migraine: Propranolol hydrochloride extended-release capsules are indicated for the prophylaxis of common migraine headache The efficacy of propranolol in the treatment of a migraine attack that has started has not been established, and propranolol is not indicated for such use.

Propranolol is effective for migraine prophylaxis, as it has been shown to reduce the headache unit index in patients with migraine 2. The recommended use of propranolol is for the prophylaxis of common migraine headache, not for the treatment of an acute migraine attack 2. Key points:

• Propranolol reduces headache frequency and severity
• Indicated for migraine prophylaxis, not for acute treatment
• Effective dose range: 20 to 80 mg, 3 or 4 times daily 2

From the Research

Propranolol for Headache

• Propranolol is a commonly prescribed drug for migraine prophylaxis, with studies showing its effectiveness in reducing the frequency of migraine attacks 3, 4, 5.
• The optimal dose of propranolol for migraine prophylaxis is still unknown, but low doses have been shown to be effective in controlling serious migraine bouts in many patients 3.
• Propranolol is considered a first-line agent for migraine prevention, along with other drugs such as timolol, amitriptyline, divalproex, sodium valproate, and topiramate 4, 6, 7.
• The choice of prophylactic drug depends on efficacy, co-morbidity, side effects, availability, and cost, with propranolol being a popular choice due to its effectiveness and safety profile 5, 6.
• Studies have shown that propranolol can halve the frequency of migraine attacks in 50% of patients, with fewer than a third of patients requiring higher doses to control migraine attacks 3, 4.

Efficacy and Safety

• Propranolol has been shown to be more effective than placebo in the short-term interval treatment of migraine, with clear evidence of its efficacy in reducing migraine frequency 5.
• The safety profile of propranolol is generally considered good, with side effects being tolerable in most patients, although higher doses may be associated with increased side effects 3, 5.
• Propranolol seems to be as effective and safe as other drugs used for migraine prophylaxis, including calcium antagonists and other beta-blockers 5.

Comparison with Other Drugs

• Propranolol has been compared with other drugs such as timolol, amitriptyline, divalproex, sodium valproate, and topiramate, with no clear-cut differences in efficacy or safety 4, 5, 7.
• Other drugs such as gabapentin, naproxen sodium, and botulinum toxin have also been shown to be effective in migraine prevention, although further studies are needed to define their role 7.