What is the recommended dose of propranolol (beta blocker) for migraine prevention?

Propranolol Dosage for Migraine Prevention

The recommended dose of propranolol for migraine prevention is 80-240 mg per day, with most patients responding to doses between 160-240 mg daily. 1, 2

Dosing Guidelines

Initial Dosing

• Start with 80 mg of propranolol extended-release capsules once daily 2
• For immediate-release formulations, divide the total daily dose into multiple administrations

Dose Titration

• Gradually increase the dose at 3-7 day intervals until optimal response is achieved 2
• The usual effective dose range is 160-240 mg once daily 2
• If satisfactory response is not obtained within 4-6 weeks after reaching the maximum dose, consider discontinuing therapy 2

Low Dose Consideration

• Some evidence suggests that lower doses (approximately 1 mg/kg/day) may be effective in about 73.5% of patients 3
• Consider starting at lower doses in patients who may be sensitive to side effects

Efficacy Evidence

Propranolol has consistently demonstrated efficacy for migraine prevention in multiple studies:

• Strong evidence supports propranolol as a first-line agent for migraine prevention 1
• Meta-analysis shows propranolol yields a 44% reduction in migraine activity when measured by daily headache recordings, and up to 65% reduction when using clinical improvement ratings 4
• Propranolol appears more efficacious in patients with pure migraine, while amitriptyline may be superior for mixed migraine and tension-type headache 1

Monitoring and Duration of Treatment

• Allow 2-3 months for full clinical benefits to become apparent 1
• After achieving a period of stability, consider tapering or discontinuing the medication 2
• If discontinuing, gradually reduce the dose over several weeks to avoid rebound effects 2

Common Side Effects

• Fatigue, depression, nausea, dizziness, and insomnia 1
• These symptoms are generally well-tolerated and rarely cause treatment discontinuation 1

Important Considerations and Cautions

• Propranolol is contraindicated in patients with:

  • Bronchial asthma
  • Cardiogenic shock
  • Heart block greater than first degree
  • Severe bradycardia
  • Uncontrolled heart failure

• Beta-blockers with intrinsic sympathomimetic activity (acebutolol, alprenolol, oxprenolol, pindolol) are ineffective for migraine prevention 1

• Long-acting (LA) formulations allow for once-daily dosing, improving adherence, but may require retitration when switching from immediate-release formulations 2

Clinical Decision Algorithm

1. Confirm migraine diagnosis and need for prophylaxis (≥2 attacks/month with ≥3 days disability/month)
2. Rule out contraindications to beta-blocker therapy
3. Start with propranolol 80 mg once daily (extended-release)
4. Assess response and side effects after 3-4 weeks
5. If inadequate response and good tolerability, increase to 160 mg once daily
6. If needed, further increase to maximum of 240 mg once daily
7. Allow 2-3 months at optimal dose to determine full efficacy
8. If effective, maintain therapy and reassess periodically
9. If ineffective after adequate trial, consider alternative first-line agents (timolol, amitriptyline, divalproex sodium)