Propranolol vs Metoprolol for Migraine Prevention
Both propranolol and metoprolol are effective for migraine prevention, but propranolol is the preferred choice as it has FDA approval specifically for migraine prophylaxis and the most extensive evidence base with 19 of 21 controlled trials demonstrating efficacy. 1, 2
Evidence-Based Recommendation
Propranolol should be your first-line beta-blocker for migraine prevention, dosed at 80-240 mg daily. 3, 4 The FDA has specifically approved propranolol for migraine prophylaxis, whereas metoprolol remains off-label despite established efficacy. 1, 3
Why Propranolol Has the Edge
Propranolol has Level A evidence (the highest grade) from the American Academy of Neurology, with consistent demonstration of efficacy across multiple high-quality trials. 4
Propranolol was effective in 19 of 21 controlled trials, representing the most extensively studied beta-blocker for migraine prevention. 2
Propranolol and timolol are the only beta-blockers with FDA approval for migraine prophylaxis, giving them regulatory endorsement that metoprolol lacks. 3, 1
When Metoprolol Is Acceptable
Metoprolol has established efficacy and receives strong recommendations from multiple guideline societies as a first-line agent, though it remains off-label. 3, 5
Consider metoprolol when propranolol is not tolerated or when cardioselective beta-blockade is preferred (e.g., patients with reactive airway disease or peripheral vascular disease). 3
Metoprolol may be chosen based on cost or formulary restrictions, as both agents are similarly inexpensive and have comparable tolerability profiles. 3
Practical Dosing Algorithm
Starting Propranolol
- Begin with 40 mg twice daily and titrate upward gradually over 2-4 weeks to minimize side effects. 3
- Target dose range is 80-240 mg daily, divided into 2-3 doses or given as extended-release once daily. 3, 1
- Allow 2-3 months for full therapeutic effect before declaring treatment failure. 3
Starting Metoprolol (if chosen instead)
- Begin with 25-50 mg twice daily and titrate to 100-200 mg daily in divided doses. 5
- Extended-release formulations can be dosed once daily for improved compliance. 5
Critical Contraindications to Avoid
Never use beta-blockers with intrinsic sympathomimetic activity (ISA) such as acebutolol or pindolol—these are ineffective for migraine prevention and should be avoided entirely. 3, 2
Absolute contraindications include:
- Bradycardia or heart block 3
- Hypoglycemic episodes in diabetics 3
- Decompensated heart failure 3
- Severe reactive airway disease (relative contraindication; metoprolol preferred if beta-blocker necessary) 3
Monitoring and Side Effects
Common adverse effects include fatigue, depression, nausea, dizziness, and insomnia—monitor specifically for mood changes and sleep disturbances. 3
Screen for depression at follow-up visits, as beta-blockers can precipitate or worsen depressive symptoms. 3
Assess efficacy at 2-3 months by calculating percentage reduction in monthly migraine days; aim for ≥50% reduction. 6
When to Choose Alternative First-Line Agents
If beta-blockers are contraindicated or not tolerated, other Level A first-line options include:
- Topiramate 50-200 mg daily 4
- Divalproex sodium 500-1500 mg daily 4
- Amitriptyline 30-150 mg nightly (especially for mixed migraine and tension-type headache) 3
The choice among first-line agents should be guided by: