Can an adult patient with migraines and possibly hypertension use propranolol and Aimovig (erenumab) together?

Can Propranolol and Aimovig Be Used Together?

Yes, propranolol and Aimovig (erenumab) can be used together, and this combination may be appropriate for patients with refractory migraine who have not responded adequately to monotherapy with either agent. 1

Evidence Supporting Combination Therapy

The 2025 American College of Physicians guidelines recommend a stepwise approach to migraine prevention, suggesting beta-blockers like propranolol (80-240 mg daily) as first-line therapy before advancing to CGRP monoclonal antibodies like erenumab. 1 However, the guidelines do not prohibit combination therapy when monotherapy proves insufficient. 1

Research evidence directly supports combining beta-blockers with other migraine preventive agents. A study examining combination therapy in refractory migraine patients showed that 62% of patients who failed monotherapy with a beta-blocker responded when a second preventive agent was added, with 44% achieving excellent (>75%) response. 2 While this study specifically examined beta-blocker plus topiramate, the principle of combining complementary mechanisms of action applies to beta-blocker plus CGRP-mAb combinations. 2

Critical Safety Consideration: Blood Pressure Monitoring

The most important clinical concern with this combination is blood pressure elevation, particularly from erenumab. Prospective real-world data demonstrate that erenumab increases both systolic BP (mean increase 5.2 mmHg) and diastolic BP (mean increase 3.5 mmHg) in treated patients. 3 A separate retrospective study found that 23.3% of patients developed worsening BP after starting erenumab, with one patient experiencing a non-ST elevation myocardial infarction attributed to hypertensive emergency. 4

Propranolol, as a beta-blocker, is recommended as first-line antihypertensive therapy and can actually help mitigate erenumab-induced hypertension. 1 This creates a potentially beneficial interaction where propranolol serves dual purposes: migraine prevention and blood pressure control. 1

Clinical Algorithm for Combined Use

Step 1: Baseline Assessment

• Measure baseline blood pressure before initiating either medication 4, 3
• Screen for propranolol contraindications: asthma, COPD, bradycardia, second or third-degree heart block, or decompensated heart failure 1, 5
• Document baseline migraine frequency (should be ≥2 attacks per month with ≥3 days of disability) 1, 5

Step 2: Initiation Strategy

• If starting both simultaneously: Begin propranolol at 80 mg daily and titrate to 160-240 mg daily over 2-4 weeks, then add erenumab 70-140 mg monthly 5, 1
• If adding erenumab to existing propranolol: Ensure propranolol dose is optimized (160-240 mg daily) before adding erenumab 5, 1
• If adding propranolol to existing erenumab: Start propranolol at 80 mg daily, particularly if BP has increased on erenumab 5, 4

Step 3: Monitoring Protocol

• Blood pressure monitoring is mandatory: Check BP at baseline, then every 3 months for the first year 4, 3
• Monitor for propranolol side effects: fatigue, depression, sleep disturbances, cold extremities 5
• Assess migraine response at 2-3 months, as benefits may not be immediate 5, 1
• In patients with pre-existing atrial fibrillation, monitor BP more closely as they have 4.9-fold increased odds of worsening BP on erenumab 4

Step 4: Management of BP Elevation

• If BP rises to Stage 1 hypertension (130-139/80-89 mmHg): Increase propranolol dose if not at maximum (240 mg daily) 5, 1
• If BP rises to Stage 2 hypertension (≥140/90 mmHg): Add a second antihypertensive agent (ACE inhibitor, ARB, or calcium channel blocker) rather than discontinuing erenumab if migraine control is good 1
• If hypertensive emergency occurs: Discontinue erenumab immediately 4

Important Caveats and Pitfalls

Do not use beta-blockers with intrinsic sympathomimetic activity (acebutolol, pindolol, penbutolol) for migraine prevention, as they are ineffective. 1, 5 Only propranolol, metoprolol, timolol, nadolol, and atenolol have proven efficacy. 5

Avoid abrupt discontinuation of propranolol. Taper gradually over several weeks to prevent rebound hypertension and potential worsening of migraine. 1, 5

The combination is particularly rational in patients with both migraine and hypertension, as propranolol addresses both conditions while erenumab provides additional migraine-specific benefit through CGRP receptor blockade. 1

Cost considerations matter. CGRP-mAbs like erenumab are substantially more expensive than propranolol, and guidelines recommend trying propranolol first unless cost is not a barrier. 1 However, if a patient has already failed propranolol monotherapy, adding erenumab is reasonable rather than switching entirely. 1, 2

Duration and Reassessment

Allow 2-3 months at therapeutic doses before declaring treatment failure, as clinical benefits may not become apparent immediately. 5, 1 If the combination is effective, continue with regular follow-up at 6-12 month intervals to assess ongoing need, adverse effects, and adherence. 5