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Beta Blocker Eye Drops Therapyfor Acute Migraine

A migraine patient reported to one of the authors (CVM) that instilling a drop of beta blocker eye drop at the earliest onset of her aura aborted the migraine attack. Subsequently other acute migraine patients have been successfully treated with beta blocker eye drops taken as early as possible at migraine symptom onset. Seven of them filled out a questionnaire which is used as the basis for these case reports. The others did not complete the form or could not be specifically identified. Table 2 summarizes our case reports described in detail above.

Patients undergo a medical history and ophthalmic examination prior to advising this method of treatment to ensure that they do not have contra-indications to beta blocker use.^{14, 15} As in glaucoma patients, the potential pulmonary and cardiovascular side-effects are discussed especially slowing of the pulse, wheezing and/or difficulty breathing. Patients are told that the eye drops are typically used in glaucoma patients and have been helpful in some patients who suffer from acute migraine attacks. They are advised to read the package insert and call if they have any questions or if symptoms develop. Treated patients have had an established, usually longstanding, diagnosis of migraine. Their physicians are informed of their acute migraine beta blocker eye drop use. New cases with symptoms suggestive of migraine are referred to their physicians for appropriate work-up to confirm the diagnosis.

Migraine patients typically put one drop of timolol ophthalmic solution 0.5% or a comparable beta blocker in each eye as early as possible in the aura or migraine evolution. Patients are advised to blink vigorously several times which encourages drop passage into the lacrimal drainage duct for enhanced systemic absorption. If no relief or partial relief of migraine symptoms occurs after 10 minutes, patients are instructed to instill another drop in each eye. If the drops do not work at this point, they are discontinued and other acute migraine medications previously prescribed by their physicians are utilized.

All of our reported cases had a complete eye examination by an ophthalmologist before therapy was started. Ideally before starting beta blocker eye drop therapy physicians should refer their patients to an ophthalmologist for a comprehensive eye examination. It is important to exclude glaucoma, lacrimal stenosis, punctal occlusion or external ocular disease.

Table 2

Conclusion

Beta blocker eye drops are inexpensive, available worldwide, and have rapid trans-mucosal systemic absorption when taken topically. Used acutely at the start of a migraine, they would be expected to cause fewer side effects than oral beta blockers and other potent prescription migraine medication. If beta blocker eye drops are effective against acute migraine symptoms, this would be a welcome addition to migraine therapy.

As with this paper, all previous publications describing the beneficial effects of beta blocker eye drops for the treatment of migraine headaches are small case reports. No controlled, prospective or retrospective study has been done on acute migraine treatment by beta blocker eye drops; such a study was first called for in 1999.² A prospective, masked, placebo controlled study, perhaps with a cross-over design, is both feasible and warranted.

Carl V. Migliazzo, MD, is a Kansas City ophthalmologist specializing in glaucoma treatment. John C. Hagan, III, MD, MSMA member since 1977, is a Kansas City ophthalmologist.

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