Metoprolol is one of the most prescribed drugs in the United States. At last count, nearly 90 millions prescriptions were dispensed annually. It has FDA approval to treat high blood pressure and heart pain (angina pectoris). This drug is sometimes injected intravenously after a heart attack patient has been stabilized. Not infrequently such patients are also sent home on oral metoprolol to reduce the likelihood of “cardiovascular mortality” after recovering from a heart attack. Many people want to know more about this commonly prescribed medication, especially metoprolol side effects.
What Are Metoprolol Side Effects?
Q. My doctor just prescribed metoprolol to control migraines and slightly elevated blood pressure at the same time. At 49, I have been trying to control my BP for more than a year through diet and exercise. It remains just slightly too high for everyone’s comfort, and seems to spike when I take sumatriptan for migraine.
I am concerned about metoprolol. Is it safe and will it really help me with both migraine and BP? I really do not want to take a drug on a daily basis.
A. Let’s start with one potential problem right off the bat: the migraine medicine sumatriptan (Imitrex) can increase blood pressure, sometimes to a dangerous level. Here’s what the FDA includes in its WARNINGS AND PRECAUTIONS section for sumatriptan:
Increase in Blood Pressure:
“Significant elevation in blood pressure, including hypertensive crisis with acute impairment of organ systems, has been reported on rare occasions in patients treated with 5-HT1 agonists, including patients without a history of hypertension. Monitor blood pressure in patients treated with IMITREX. IMITREX Tablets are contraindicated in patients with uncontrolled hypertension.”
Sumatriptan Side Effects:
- Heart attack, heart pain, angina, chest tightness and/or pressure, jaw pain, palpitations
- Spasms in blood vessels leading to belly pain, bloody diarrhea, cold hands and feet, etc.
- Serotonin syndrome, especially when combined with SSRI-type antidepressants. Symptoms include agitation, hallucinations, uncontrollable muscle contractions and/or movements, rapid heart rate, elevated temperature, digestive distress and coma
- Severe allergic reactions, anaphylaxis
- Abnormal sensations, tingling, numbness, prickling feelings
Although sumatriptan can be a very useful drug for the treatment of migraines, it does pose a problem for people with a susceptibility to high blood pressure.
Metoprolol and Migraines:
Metoprolol can help reduce the frequency of migraines. The FDA has not approved this beta blocker heart medicine for the prevention of migraines. Prescriptions for metoprolol for this indication are considered off-label. That said, the American Academy of Neurology has published guidelines that “support the use metoprolol” for this purpose (Continuum, Aug., 2015).
Based on the available evidence the authors note:
“Beta-blockers are the most widely used class of drugs in prophylactic migraine treatment and are about 50% effective in producing a greater than 50% reduction in attack frequency.”
Metoprolol and High Blood Pressure:
The case for using metoprolol (or other beta blockers such as atenolol or propranolol) as first line drugs against hypertension is much less secure. Franz Messerli, MD, is Professor of Medicine at Mount Sinai Health Medical Center. He is arguably one of the grand old men of preventive cardiology. He has written extensively about the use of beta blockers as first-line treatments for hypertension [HTN].
Please pardon the medical jargon, but in the editorial comment in the Journal of the American College of Cardiology (Sept. 22, 2009), Dr. Messerli and his colleagues are extremely candid.
“Beta-Blockers as First-Line Antihypertensive Therapy:
The Crumbling Continues.”
Under the title of their article is a quote from Mark Twain:
“Supposing is good but finding out is better.”
Here is what Dr. Messerli and colleagues say:
“Compared with other agents used in the treatment of uncomplicated HTN [hypertension], BBs [beta blockers] have a number of potential adverse effects. In fact, after 4 decades of using BBs as primary treatment for HTN, no study has shown reduced morbidity or mortality when used as monotherapy when compared with placebo. In contrast, many meta-analyses have suggested the potential detrimental effects of these agents. In a recent meta-analysis of 12 studies evaluating over 90,000 patients with HTN, BB therapy resulted in a 22% increased risk for new-onset diabetes mellitus, a known powerful risk factor for CV [cardiovascular] disease. Recent studies have focused on the epidemic in obesity and therapy with BBs might be associated with weight gain…”
In their concluding remarks these authors ask the question:
“On the basis of the current information, how should clinicians currently proceed when treating patients with HTN? The seminal question to be asked is: “Are BBs still alive as first-line therapy for HTN?”
“…for the patient with HTN without other compelling indications, the evidence supporting BB therapy has vanished…Thus, in response to Mark Twain, we no longer need to suppose–we have found out!…Finally, as the evidence supporting BBs as first-line therapy for HTN continues to crumble, one could answer the question posed earlier, “Maybe alive, but barely breathing!”
NEVER Stop Metoprolol Suddenly!
No one should EVER stop beta blocker treatment suddenly. That could lead to angina, heart attacks and other serious complications. Patients who are treated with beta blockers as first-line therapy for hypertension should discuss this article with their prescribers. There may be a compelling reason for metoprolol. It may also be helpful to ask the question: What are metoprolol side effects? To help further the discussion with a prescriber, we list the following from the Food and Drug Administration:
Metoprolol Side Effects:
According to the FDA:
Central Nervous System:
“Tiredness and dizziness have occurred in about 10 of 100 patients. Depression has been reported in about 5 of 100 patients. Mental confusion and short-term memory loss have been reported. Headache, nightmares, and insomnia have also been reported.”
“Shortness of breath and bradycardia [slow heart rate] have occurred in approximately 3 of 100 patients. Cold extremities; arterial insufficiency, usually of the Raynaud type; palpitations; congestive heart failure; peripheral edema; and hypotension have been reported in about 1 of 100 patients…”
“Wheezing (bronchospasm) and dyspnea [shortness of breath] have been reported in about 1 of 100 patients. Rhinitis has also been reported.”
“Diarrhea has occurred in about 5 of 100 patients. Nausea, dry mouth, gastric pain, constipation, flatulence, and heartburn have been reported in about 1 of 100 patients. Vomiting was a common occurrence….”
“Pruritus [itching] or rash have occurred in about 5 of 100 patients…
The FDA considers these metoprolol side effects quite rare, but does list them:
Peyronie’s disease [bent penis syndrome], hair loss, dry eyes, blood disorders, weight gain, memory loss, confusion, increased triglyceride levels, decreased HDL cholesterol and arthritis.
Other Ways to Control Hypertension:
You describe your blood pressure as “just slightly too high for everyone’s comfort.” You did not provide us with actual numbers so we cannot comment on your situation. The sumatriptan you have been using for migraine attacks may be contributing to your elevated blood pressure readings.
We are sending you our Guide to Blood Pressure Treatment so you will have more information on metoprolol and non-drug approaches to controlling hypertension. Anyone who would like a printed copy, please send $3 in check or money order with a long (no. 10) stamped (70 cents), self-addressed envelope:
- Graedons’ People’s Pharmacy, No. B-67,
- P. O. Box 52027,
- Durham, NC 27717-2027.
It can also be downloaded at this link.
Share your own experience with metoprolol and/or sumatriptan below in the comment section.