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Review Reaffirms Beta-Blockers for Migraine Prevention

Allison Inserro
A recent literature review assessed the efficacy of beta-blockers to prevent migraine and tension headache. It found that propranolol worked better than placebo for episodic migraine headaches, but the evidence for efficacy in tension headaches was limited.
A recent literature review assessed the efficacy of beta-blockers to prevent migraine and tension headache. It found that propranolol worked better than placebo for episodic migraines, but the evidence for efficacy in tension headache was limited.

The researchers combed through 8 databases, including the Cochrane Register of Controlled Trials and MEDLINE.

This study included 108 randomized controlled trials, 50 placebo-controlled trials, and 58 comparative effectiveness trials. Compared with placebo, propranolol reduced episodic migraine headaches by 1.5 headaches per month at 8 weeks (95% CI, –2.3 to –0.65) and was more likely to reduce headaches by 50% (relative risk [RR], 1.4; 95% CI, 1.1-1.7).

A network analysis suggested that beta-blockers’ benefit for episodic migraines may be a class effect. Trials comparing beta-blockers with other interventions were largely single, underpowered trials.

Propranolol was comparable with other medications known to be effective, including flunarizine, topiramate, and valproate. For chronic migraine, propranolol was more likely to reduce headaches by at least 50% (RR, 2.0; 95% CI, 1.0-4.3).

The effect began as early as 4 weeks, with migraines reduced by an average of 1.3 headaches per month. Patients also reduced the amount of analgesic medications; in addition, residual headaches were less severe and shorter in duration compared with those receiving placebo.

Outcomes from the propranolol comparisons to placebo were rated as high-quality evidence.

In 3 trials, metoprolol also reduced headache frequency, although the reduction was less than 1 headache a month. Conclusions regarding the efficacy of other beta-blockers is less certain, as most were studied in just 1 trial each.

However, there was only 1 trial of beta-blockers for tension headache. It compared the combination of pindolol and amitriptyline with placebo and with amitriptyline alone. The combination of pindolol and amitriptyline was more effective than placebo at reducing headache frequency at 4 and 8 weeks and in reducing headaches by at least 50% (RR, 3.8; 95% CI, 1.5-9.3), but it was equally as effective as amitriptyline.

Studies had a number of common quality problems, including high drop-out rates (16.1%; range, 0-51%), lack of intention to treat analysis (76%), inadequate sequence generation (83%), lack of evidence of concealed allocation (90%) and inadequate blinding (60%). Twenty-three (21%) studies assessed compliance. Fifty-one (47%) studies reported all collected outcomes. Sixteen trials (15%) were sponsored by industry.

The American Headache Society updated its position statement last year on preventing and treating migraine to include calcitonin gene-related peptide inhibitors; the beta-blockers on the list include metoprolol, propranolol, timolol, atenolol, and nadolol.

Reference

Jackson JL, Kuriyama A, Kuwatsuka Y. Beta-blockers for the prevention of headache in adults, a systematic review and meta-analysis [published online March 20, 2019]. PLoS One. doi: 10.1371/journal.pone.0212785.

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