I wanted to share my patient experience with timolol drops for migraine in case it may help others. I have been using timolol malate ophthalmic solution for the past three years as both a vestibular migraine preventive and, most recently, as an acute treatment. This post was originally published July 22, 2019 and recently updated on December 30, 2020 with new research via Dr. John Hagan.
When my neurologist first prescribed this medication, like any curious patient I took to the internet to search through everything I could about it. I checked all my migraine support groups, yet I could find nothing on timolol drops for migraines. There was some info on the pill form, but not much on the drops. It seemed like I was the only person in the world on this particular medication. Beta blockers in pill form, like propranolol, have been used for years to treat migraine disorders, yet this was a method that seemed to be rarely used.
At my following appointment with Dr. Beh, I asked him why he recommended it to me. He mentioned that there’s a tendency for beta blockers to have greater side effects when in pill form, but as an eye drop it can be absorbed quickly into the blood stream, making a very small amount of medication highly effective. Used in this form, I could have faster relief but with lowered risk of side effects.
Research on Timolol Malate
The first study on the use of beta blocker eye drop treatment of headaches was in 1980, however, not much had been followed up with it until 2014. In studies, timolol in pill form has been found to be just as effective as propranolol in migraine prevention at 20-30mg a day. Yet with the oral dosage of beta blockers being the most popular prescription, it absorbs too slowly to be considered an acute treatment. Timolol received FDA approval in 1978 for the treatment of glaucoma, and when used as eye drops, patients would report the added benefit of a reduction in migraine attacks.
Ophthalmologists Hagen and Migliazzo put these observations together and published a study in 2014 in The Journal of the Missouri State Medical Association. Five out of their seven patients reported complete pain relief, while the other two reported a significant reduction in pain relief when used in their acute migraine attacks. The idea is that beta blocker eye drops reach therapeutic levels within minutes of application without causing unwanted side effects.
- In 2018, a study of patients who met the International Headache Society’s requirements for migraine received timolol maleate eye drops in 0.5% dosage, a single drop in each eye, at the onset of symptoms and once again 30 minutes after. The study took place over a 4 month period, where ten patients scaled their pain from 0 to 3, and rated the effectiveness of the drops when used for their attacks. Timolol was rated at a 2.4 in effectiveness when the placebo was rated at 1.4.
- Four of the patients rated this treatment as highly effective and only one had an adverse reaction to the treatment. Of all the migraine attacks reported, 37 out of 55 had no symptoms to mild symptoms when the timolol treatment was used early.
- In 2019, Dr. Carl Migliazzo and John Hagan III called for more research into this promising medication and shared a story from Carolyn Csongradi, who had tried a multitude of migraine medications with terrible side effects from propranolol to nortriptyline. With her mild persistent asthma, she could not take Imitrex-type drugs or other oral beta blockers. Although typically not recommended for asthma, her neurologist agreed to let her try 2 drops of 0.25% a day in each eye. It has proven to be a successful abortive medication for her without side effects or a negative impact on her asthma.
- In 2020, Dr. Bradley J. Katz published an article on JAMA Ophthalmology called “Pulled a Drop of Timolol Into Each Eye and Call Me in the Morning” recommending Timolol as “inexpensive” and a “very good adverse event profile and safety profile”. It also called to attention the observations of the authors that there may be even larger benefits as a nasal spray because of the rapid absorption, similar to Sumatriptan.
- In May-June 2020, Dr. John C. Hagan III along with Eric Everett, RPh and Tyler Chamberlain discussed using Timolol sublingually as well as a nasal spray. They recommend the nasal spray for those who have trouble properly doing the eye drops, perhaps cause of the stinging sensation. Their research shows nasal administration to be the fastest absorbed and most effective. However, currently you can only get this prescribed through them (available through O’Brien Pharmacy)
Side Effects
The current medications used in acute treatments, like NSAID’s and triptans, come with a risk of rebound attacks when used too often. Since beta blockers are already used as a daily migraine preventative treatment, it’s likely they wouldn’t carry that same risk.
Side effects of traditional beta blockers can include lower blood pressure or an adverse effect on asthma. However, the dosages in pill forms are much higher than what can be taken in the eye drop form, meaning there would be a lowered risk of these potential side effects. Also, if taken as an abortive and not a preventative medication, some with low blood pressure find they can tolerate it well.
As you can see above, patients with asthma have been able to use them without adverse reactions. My vestibular migraine friend who is also a patient of Dr. Beh’s, Kayla McCain, manages to use them without and adverse effect on her asthma (although our physician, and myself, had to really twist her arm on trying it!).
Since these drops are used often for glaucoma, it should come with little to no risk to the eyes, however a meeting with an ophthalmologist is always essential. In the beginning, I found the drops stung for a few seconds when first applied, yet it quickly went away. If this is an issue for you, you could try Dr. Hagan’s suggestion to use them sublingually or contact their pharmacy to check on the nasal spray. The nasal spray is $30 plus postage.
Timolol for Vestibular Migraine
I was prescribed the 0.5% solution with instructions to take it 2x a day, at night and in the morning as a preventative medication. Then I could use it as needed, as an acute medication, for bad attacks. It did take a while for me to notice a reduction in symptoms, a couple of months at least. However, I was not the kind of patient who expected results overnight. I stayed the course and kept doing what I was supposed to. I think what helped me the most was combining these drops with other preventative measures, like diet and supplements.
Now that my vestibular migraine is fairly well controlled, I use the timolol eye drops as an abortive or rescue medication. Just a drop in each eye when I feel my dizziness kick up seems to help ease my head a bit and lessen an attack. I find this is also true for my other friends with head pain associated with their migraine.
Since I started taking it several years ago, I spread the word about how much it was helping me and now several migraine friends are finding success as well.
A Note on Pregnancy
My OB has approved these as an acute medication and a preventative for post pregnancy. Beta blockers are typically one of the approved meds, should women with migraine need the option. You can read more about my experience using them while trying to conceive. This is a big reason why I made them apart of my original treatment plan.
Talking to Your Neurologist about Timolol Drops
So why did it feel like I was the only person in the world on it? First of all there wasn’t a ton of research on it at the time, even though the research out there is positive, so a lot of the successful feedback came from Dr. Beh’s own patients like myself.
The other reason? Money. Pharmaceutical companies don’t really want to invest in a drug that they cannot market. There’s more money involved with all the new anti-CGRP treatments and Botox, which means more research. For a generic eye drop, it’s not going to get a lot of attention or money invested into it. (If you check out this study, don’t miss all the ads for anti-CGRP or Botox that surround it and you’ll see what I mean.) Dr. Hagan recently reached out to me in December 2020 to mention he has been trying to get Big Pharma to develop this medication over the past 6 years.
If you’re curious to try this treatment, I recommend printing out all the studies and approaching your neurologist about it. The feedback I typically hear is that they have either never heard of this, or the trials weren’t large enough to prove anything significant. While that might be true, there are lots of treatments when it comes to migraine, especially vestibular migraine, that aren’t backed by massive studies. I feel that it’s these small, yet very positive, studies that can make a huge difference in some of our lives. It certainly did for me!
A big thank you to Dr Hagan for providing these linked updated articles and materials, as well as pushing for this medication for our community.
Other Articles on Timolol and Migraine
For more posts on vestibular migraine and other articles using Timolol for migraine management, see these articles:
Vestibular Migraine Symptom Guide
Acute Treatments for Vestibular Migraine
5 Ways to Relieve a Migrainous Vertigo Attack
TTC and Pregnancy with Migraine
My Vestibular Treatment Plan
Referenced materials:
1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6312165/
2. https://jamanetwork.com/journals/jamaneurology/article-abstract/2680666
3. https://headaches.org/2016/07/01/use-beta-blocker-ophthalmic-solution-treatment-migraine/
4. http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/neurology/headache-syndromes/
5. https://www.ncbi.nlm.nih.gov/pubmed/2879629
6. https://www.neurologylive.com/clinical-focus/timolol-migraine-shows-efficacy-abortive-therapy
7. https://www.msma.org/uploads/6/2/5/3/62530417/beta_blocker_for_migraines_julyaug2014_momed.pdf
Asking my HAS about these this week!
Bring some of these studies with you!
Thank you Alicia! I will do some follow up study and consider.
Hi Alicia, Thank you for all the very helpful info! I actually remember reading about Timolol a couple years ago, I brought it up to my neurologist but she just seemed confused and directed me to propranolol. I didn’t know enough about Timolol at the time so I didn’t press the subject. I was excited to read it’s been effective for you! I plan to follow up with my doctor about it tomorrow. I’m really trying to get off the Naproxen/Naratriptan roller coaster. On a separate note, have you read about Topical Bimatoprost in the treatment of migraine? Bimatoprost is the same as Latisse, they’re amongst trials right now but they theorize brushing it on fingernails could be helpful for migraine prevention. I’m always hopeful for an answer to my migraines. Thank you again for all the great articles.
Melissa
I have not but that sounds super interesting! I’ll definitely be looking into it. I wish you such great success with trying to get out of that rebound cycle. So glad this could be a helpful option!
Hi Alicia! I’m only a two days into this journey and your website and IG has already been a huge support and blessing! Thank you so much!
I have talked with my neurologist at the University of Kansas Hospital and she said she was part of the trial that studied timolol drops and like you said, the results were not statistically significant enough to show a benefit… however she did tell me I could try it as an abortive but not at a twice daily preventative. I am still in my 24/7 cycle of dizziness so I was hoping to be able to try what you did. She said she was open to any other literature and articles that suggested it to be helpful on a daily basis… Have you seen anything like this? Or how did your doctor come to the conclusion to have you on it daily?
Thanks again for you support and your time!!
Hey Emily, Timolol is a very common migraine preventative with a lot of research behind it so I’m not sure if she’s looking for research on the drops specifically? There is no research for the drops specifically as a preventative (the post gives a clue why this may be). Essentially it’s the same medication though. My neuro is at UTSW which is a research hospital so I believe they are more open to testing treatments out with patients who are willing. My appointments usually last about an hour and they take thorough notes on what’s working and what’s not for other patients. I was open to it because it was a lower dosage than the pill form and it seemed fairly easy to wean off of compared to other medications.
There are many different medications out there that help VM though so don’t feel like this is the only one that works. Dr Hain actually has a great chart on it. Timolol was just the best one for me since I couldn’t TTC on many of the other medications.
Same here. My doc gave as an abortive, not preventative. How long were you doing it daily for? How long before results? Thanks for your information on this!
I did it daily for about 2 years, I think? Somewhere around there. I probably saw results within 3 months but that was also combined with supplements and diet changes. Now that I’m not 24/7 chronic I can use them easily as an abortive. It works pretty fast!
I was initially part of the University of Kansas Department of Neurology study on the use of timolol eye drops for acute migraine. The study design and execution were atrocious and the results totally in error. The lead researcher had never done a major study and the first draft was done by a medical researcher who had never written a paper. I retained an attorney to get my name off the paper. The paper was NOT peer-reviewed and published in an appendix to the KS Med J. I sent a published letter to the editor pointing out all the errors and problems with the study which was published. The authors of the study chose not to respond because they could not defend their results. JAMA Ophthalmology October 2020 has a wonderful study from medical school in India that did placebo controled study on timolol eyedrops for acute migraine in 50 patients, largest to yet be studied and found a highly statistical significant benefit, a smaller study of 10 patients done at UMKC School of Medicine in Kansas City and published in JAMA Neurology found 40% of the patients benefited.
February 2019 I had a sudden intense earache, strep throat, wheezing after attending a field trip with a friend who was coughing badly and later I found out she had the flu. I thought it was a virus so was treated at a clinic for that with antibiotics and steroids. When I got to my ENT he suggested VM but another doctor said it was a mastoid infection so treated me for that for months. I followed the diet anyway. I had constant dizziness, tinnitis, awful head and ear pressure and headaches. I was prescribed Noritriptyline or Elavil which is hard because I have RLS. Neurologists didn’t understand VM. One said I can try Aimovig so I did and not sure if that helped. I went off the diet and Elavil and was doing better but recently it came back so I am confused. I will ask about the eye drops. I feel so desperate for clarity on this. Thank you. Susanne
So sorry you’re struggling Susanne. It often takes a few different types of treatments and meds before we find the perfect one for us. I recommend reading Dr. Beh’s new book and sharing with your doctors as well.
Thank you for posting this and providing the resources to approach the neurologist. I’ve struggled with side effects of all the standard drugs and neurologist just gave me the go ahead to try this after sharing the papers you referenced. He had never heard of it, so I would have been out of luck without this.
So happy to hear this Chris. I do find a lot of doctors are more open to trying after seeing some of the research, even if it is small.
Hi Alicia,
Before you achieved baseline, how did you use timolol eye drops?
Was it one drop on each eye twice a day?
Were you on any other medications during that time?
How long before you discontinued daily usage?
Thanks so much for your site and thank you for spreading the word on this.
I was prescribed 1 drop 2x a day and then as needed for attacks. The other treatments I was doing are listed in this post. I think it will answer a lot of your questions! IF the post is too long for you to read, I have a corresponding video linked in it that you can listen to.
Hi Alicia,
Dr Cho at the House Ear Clinic, who I love by the way, recently prescribed these eye drops. It was more for acute attacks but he said if I feel pressure(which I do everyday), I can use as needed. I am going to do two drops a day (I will let him know). I am currently on 100mg of nortriptyline and off of all caffeine and chocolate. I have seen a big improvement with my Meniere’s symptoms since I started treatment for vestibular migraines. I still have the tinnitus in the left ear but it isn’t as bad and the sound distortion has improved. In one week’s time that improvement really kicked up a notch when I started these eye drops. The constant rocking is now more of a feeling I have when I am standing still or getting ready for bed. All my symptoms are worse in the evening. Prayers to all my fellow sufferers.
Can you take the eye drops and a migraine med at the same time when you get one? Meaning would the eye drops interact with the other prescribed medication.
You should ask your migraine physician about this. Beta blockers (specifically timolol 0.5%) work WITH (doctors call it synergistically) other acute migraine abortants. Most of the patients I have treated or been consulted on do NOT use timolol eye drops as their sole therapy. Many take analgesics or anti-inflammatories. some tryptans or other acute migraine inhalers.
Hi there Alicia,
Thank you for this information and inf fact all your information, it is a great source of comfort. Dr Beh is my doctor too. He prescribe these to me last week. And when I tried to ask a few follow up questions it’s almost impossible to get hold of him. So I am going to ask you…… I wasn’t sure if it was a medication that has to built up in your system or it’s work straight away (like an Advil would). Because I’ve taken it the last two or three days and it certainly hasn’t really make a difference. But when doing research it says that it should work straight away…. anyway I was curious to see if it’s something I have to take for months before I see any results – thank you x
It depends on how you are taking it. If for chronic migraine prevention and you take the timolol drops twice/day it may take 30 days for a trial. This presumes you are not on any other beta blockers for any reason and that you take other migraine meds that help you. If you take for acute migraines, that is 2 drops under tongue or one drop to eye at the earliest onset of an acute migraine along with your other acute migraine medications, and take a second set of drops 10 minutes after the first if your headache is still a problem , you should be able to tell after 2 acute migraines if they will be helpful.
I very much appreciate your time in answering me back. Thank you, John. Great info.
I took preventatively in the beginning and it took me a month or two to really notice it was helping. It definitely wasn’t immediate. Now I see more of a quick benefit, but I’m not 24/7 bad like I used to be so I think it’s easier for me to tell as well.
Thank you so much x