Beta-blockers, particularly propranolol have been the most widely used prophylactic agents in migraine.  They have shown to be 60-80% effective in producing greater than 50% reduction in attack frequencies.  Many controlled studies²⁷⁸ have shown that propranolol, metoprolol, timolol, nadolol, and atenolol reduce the frequency of attacks in patients who have migraine with and without aura.^185,252 All beta-blockers do have side effects such as drowsiness, fatigue, lethargy, sleep disorders, nightmares, depression and, rarely esophageal spasm.  Less common side effects include orthostatic hypotension, significant bradycardia, impotence, and aggravation of intrinsic muscle disease.  Such drugs have specific contraindications including asthma, heart block and congestive heart failure.   Long acting forms of propranalol may be helpful in some patients, but are significantly more expensive and less flexible in dosage.  Studies have been carried out with other beta‑blocking agents but none have been superior to propranalol. There are clearly some patients who are responsive to one and not to other drugs in this class, so if a patient does not respond to propranalol it is reasonable to proceed with nadolol, (80‑240 mg), atenolol (50‑100 mg) or timolol (20‑100 mg). Determination of plasma propranolol concentrations have demonstrated that different responses to the same oral dose do not depend on different plasma levels of the drug.²⁷⁹  Therefore, clinical response to such agents would seem to be linked to individual sensitivity.  Several articles and text discuss the overall approach to the treatment of vascular headaches.^{14,15,237,279}