CGRP vs Propranolol: Preventive Benefit in Youth With Migraine and Dysautonomia

Dysautonomia symptoms are prevalent among children and adolescents with primary headache disorders, and propranolol may offer a dual benefit to such patients, according to study results presented at the 2025 American Headache Society (AHS) Annual Scientific Meeting, held from June 19-22, in Minneapolis, Minnesota, and virtually.

The mechanisms of migraine and dysautonomia often overlap and co-occur, but the relationship between the two is not well understood. Prior research has indicated that dysautonomia may play a role in the pathophysiology of migraine, but questions about potential shared mechanisms require further investigation. Propranolol, which is commonly used as migraine prevention, may also provide an additional benefit in patients with dysautonomia by stabilizing heart rate and blood pressure.

Researchers conducted a retrospective review of electronic medical records (EMRs) of patients who visited a clinic between January 2018 and July 2024 to assess the safety and efficacy of calcitonin gene-related peptide (CGRP)-targeted migraine prevention therapies vs propranolol/metoprolol in patients with co-existing diagnoses of dysautonomia and headache disorders.

The primary outcome was mean monthly headache frequency, and the secondary outcome was the frequency of the most bothersome dysautonomia symptoms.

A total of 35 EMRs were included in the study (participant age range, 11-19 years; women, n=30). Overall, 44% of participants were started on CGRP-targeted therapies, and 56% were started on propranolol or metoprolol. Most participants (68%) had a diagnosis of chronic migraine, followed by episodic migraine (23%), new daily persistent headache (9%), and post-traumatic headache (1%).

A statistically significant reduction in the mean number of monthly headache days (vs baseline) was observed for the CGRP-targeted therapies (22.5 days pre-initiation vs 16.3 days post-initiation; P =.016) and propranolol/metoprolol (23.4 days pre-initiation vs 16.2 days post-initiation; P =.013).

The median number of headache days in the CGRP-targeted group was 30 pre-initiation (range, 4-30) and 20 post-initiation (range, 2-30); median number of headache days in the propranolol/metoprolol group was 30 pre-initiation (range, 4-30) and 8 post-initiation (range, 0-30).

In patients with migraine, the most bothersome dysautonomia symptoms was light-headedness (100%), followed by palpitations (68%), syncope (68%), and positional vision fading (60%).

“Future studies utilizing quantifiable scales to assess dysautonomia symptoms in this cohort could provide valuable insights into whether combining these therapies may offer an integrated treatment strategy for patients dealing with the complex interplay of migraine and dysautonomia,” the researchers concluded.