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Beta Blocker Eye Drops For Treatment of Acute Migraine

By Carl V. Migliazzo, MD & John C. Hagan, III, MD

Abstract

We report seven cases of successful treatment of acute migraine symptoms using beta blocker eye drops. The literature on beta blockers for acute migraine is reviewed. Oral beta blocker medication is not effective for acute migraine treatment. This is likely due to a relatively slow rate of achieving therapeutic plasma levels when taken orally. Topical beta blocker eye drops achieve therapeutic plasma levels within minutes of ocular administration which may explain their apparent effectiveness in relief of acute migraine symptoms.

Introduction

Sporadic case reports have suggested that beta blocker eye drops are effective for acute migraine treatment and chronic prevention of migraine attacks^1-5 (see Table 1). Although widely prescribed for glaucoma therapy, beta blocker eye drops are rarely used for acute or chronic migraine treatment. Recent comprehensive reviews on migraine therapy do not mention the potential therapeutic value of beta-blocker eye drops.^{6, 7, 8, 9}

Oral beta blocker medications are commonly and successfully used for chronic migraine prophylaxis.^{7, 8, 9} However, beta blocker medications taken orally are not effective in treating acute migraine.^{10, 11} applied beta blocker eye drops are systemically absorbed by the nasal mucosa and therapeutic plasma levels are achieved within minutes.^{4, 12, 13}

In this paper we report seven cases which describe the successful use of beta blocker eye drops to abort or attenuate acute migraine symptoms. The scant published literature on using beta blocker eye drops to treat migraine is reviewed.^1-5 We present an explanation of why beta blocker medication by topical eye drop, but not by oral administration, may be effective for acute migraine treatment.

Table 1 

Case Presentations

Case 1

CH is a 61-year-old female who has suffered from migraines for approximately 30 years. Her typical migraine is a throbbing, right-sided pain that radiates to her neck and shoulders, occasionally associated with nausea, and a preceding visual aura. Her headache will last one to two days if not treated. Previous trials of oral medications, the names of which she does not remember, did not give her sufficient relief, so she stopped using them. Approximately 15 years ago she began using at onset of acute migraine levobunolol 0.5% ophthalmic solution one drop in each eye along with ibuprofen 600 to 800mg orally. She rates her headache relief as a 10 on a scale of 1 (no relief) to 10 (complete relief) since she started using topical beta blocker eye drops. She has had no side effects from the drops and only uses them for acute attacks.

Case 2

MM is a 66-year-old female who describes the onset of her migraines as throbbing, one-sided, pain sometimes lasting for up to three days. Nausea and sensitivity to light, sounds and smells are often associated with her headaches. Her symptoms began 32 years ago and for the past eight years she has used prophylactic topiramate 50mg bid and nadolol 40mg at bedtime. Approximately one year ago she began using topical timolol 0.5% ophthalmic solution one drop in each eye at the onset of her attack. Within 15 to 30 minutes she gets complete relief (10 on a scale of 1 to 10) of her symptoms. Occasionally, she will take Fioricet^® with codeine along with her eye drops; most of the time does not. She has experienced no side effects from the drops and only uses them for an acute attack. She feels that the management of her migraines has been greatly improved with the addition of topical beta blocker eye drops.

Case 3

DW is 38-year-old female who first noticed the onset of her migraines about 25 years ago. She describes an acute attack as a constant pain that begins in her right temple and then radiates to a throbbing vein in her left temple. Associated symptoms include nausea, vomiting, blurred vision, light and noise sensitivity, diaphoresis, and confused mentation. Duration of attacks without treatment is 24 hours or more. She has tried several different oral drugs for the past 14 years and they would take several hours before she had any relief of symptoms. Most of the time she tries to fall asleep. Two years ago she began using topical timolol 0.25% ophthalmic solution one drop in each eye at the onset of a migraine. She noticed some slight shortness of breath and now only uses one drop in one eye and has no side effects. Symptom relief begins in about 10 to 20 minutes and she rates her relief as an 8 on a scale of 1 to 10. Although her symptoms are not completely relieved with one drop, she is at least able to function. If a migraine is particularly severe, she will take oral analgesic medications after instilling an eye drop.

Case 4

EM is a 61-year-old female who describes the onset of her migraines as a visual aura with a classic fortification scotoma that begins with blurred central vision then expands towards the periphery until her central vision clears. This is followed by a one-sided, constant headache associated with nausea, light and sound sensitivity, and pain behind her eyes. Untreated duration of these attacks is 24 hours or more. Prior to using eye drops, oral ibuprofen would give partial relief in about 30 to 60 minutes. Often, she would go to bed and try to fall asleep. About five years ago she began using topical timolol 0.5% ophthalmic solution one drop in each eye at the first onset of a visual aura. Within two minutes she rates her relief of symptoms as 9.5 on a scale of 1 to 10. If she does not instill the drops at the very first visual symptom, relief may take longer, but usually within 10 to 20 minutes. She continues to take ibuprofen along with her topical beta blocker eye drops and has had no systemic or ocular symptoms from the eye drops. She only uses the drops for an acute attack and does not use them prophylactically.

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