What beta‑blocker and dosing regimen should I use for migraine prophylaxis in an adult with episodic migraine and no contraindications (asthma, severe bradycardia, atrioventricular block, uncontrolled heart failure, active depression)?

Beta-Blocker Selection for Migraine Prophylaxis

For an adult with episodic migraine and no contraindications, propranolol is the first-line beta-blocker of choice, starting at 80 mg once daily (extended-release formulation) and titrating to a usual effective dose of 160-240 mg once daily. 1, 2

First-Line Beta-Blocker Options

The following beta-blockers have established efficacy for migraine prophylaxis:

Propranolol (Preferred)

• Start at 80 mg once daily using extended-release formulation 2
• Target dose: 160-240 mg once daily for optimal migraine prophylaxis 2
• Can be given as long-acting formulation once or twice daily (80-160 mg) 1
• Maximum studied dose: 320 mg/day for migraine (higher doses lack established safety/efficacy) 2
• Most extensively studied beta-blocker with clear evidence of superiority over placebo in 26 controlled trials 3, 4

Alternative Beta-Blockers (If Propranolol Not Tolerated)

• Metoprolol: 50-100 mg twice daily OR 200 mg modified-release once daily 1
• Atenolol: 25-100 mg twice daily 1
• Bisoprolol: 5-10 mg once daily 1
• Timolol: Effective but dosing not specified in guidelines 1

Dosing Strategy and Titration

Starting Low-Dose Propranolol

• 73.5% of patients respond to low doses (approximately 1 mg/kg body weight daily or less) 5
• Begin with 80 mg once daily and assess response over 4-6 weeks 2
• If inadequate response after 4-6 weeks at maximal dose, discontinue and consider alternative prophylaxis 2

Gradual Titration

• Increase dose at 3-7 day intervals if needed to achieve optimal response 2
• Most patients achieve control at 160 mg once daily 2
• Fewer than one-third of patients require higher doses beyond initial low-dose trial 5

Critical Contraindications to Avoid

Beta-blockers with intrinsic sympathomimetic activity (ISA) are INEFFECTIVE for migraine prophylaxis and should be avoided: 6, 7, 8

• Alprenolol, oxprenolol, pindolol, acebutolol have NOT demonstrated efficacy 8

Treatment Duration and Monitoring

Evaluation Timeline

• Assess efficacy after 2-3 months of consistent use at target dose 1, 6
• Key outcome measures: attack frequency, attack severity, migraine-related disability 1
• Continue treatment for 6-12 months after achieving sustained efficacy before considering discontinuation 6

Discontinuation Protocol

• Reduce dosage gradually over several weeks when stopping treatment 2
• Abrupt discontinuation should be avoided, particularly in patients with cardiovascular considerations 2

When to Consider Alternatives to Beta-Blockers

If propranolol or other beta-blockers fail after adequate trial:

• Candesartan 16 mg once daily (can increase to 32 mg) is a first-line alternative with strong evidence 6, 9
• Topiramate 50-100 mg daily (target 100 mg/day) is another first-line option 10
• Second-line options include amitriptyline (10-100 mg at night) or flunarizine (5-10 mg once daily) 1

Common Pitfalls to Avoid

• Do not use beta-blockers with ISA (intrinsic sympathomimetic activity) as they lack antimigraine efficacy 6, 7, 8
• Do not underdose: Many patients receive subtherapeutic doses; ensure adequate titration to 160-240 mg/day range 2, 5
• Do not assess too early: Allow minimum 4-6 weeks at target dose before declaring treatment failure 2
• Do not stop abruptly: Taper gradually over weeks to avoid rebound effects 2