Propranolol Starting Dose for Migraine Prophylaxis
The recommended starting dose of propranolol for migraine prophylaxis is 80 mg once daily when using the extended-release formulation, with a usual effective dose range of 160-240 mg once daily. 1
Dosing Guidelines
Initial Dosing
- Start with 80 mg propranolol extended-release capsules once daily 1
- For immediate-release formulations, the dose should be divided (typically 40 mg twice daily)
- Some patients may respond to lower doses of approximately 1 mg/kg body weight daily 2
Dose Titration
- Gradually increase the dose at 3-7 day intervals until optimal response is obtained 1
- The minimum time interval between dose increases should be 24 hours
- Evaluate response after 4-6 weeks of treatment at each dose level
Maintenance Dosing
- The usual effective dose range is 160-240 mg once daily for extended-release formulations 1
- If a satisfactory response is not obtained after 4-6 weeks at the maximum dose, propranolol therapy should be discontinued 1
Efficacy Considerations
Propranolol has consistently demonstrated efficacy for migraine prevention at doses ranging from 80-240 mg/day 3. Research shows:
- Low doses (around 1 mg/kg/day) are effective in controlling migraine attacks in approximately 73.5% of patients 2
- Only about one-third of patients require higher doses for adequate migraine control 2
- Propranolol is more efficacious in patients with pure migraine headaches compared to those with mixed migraine and tension-type headaches 3
Safety Considerations
Pretreatment Assessment
- Cardiovascular and respiratory examination is required before starting propranolol (auscultation, peripheral pulses, abdominal examination) 3
- ECG may be needed in selected cases, particularly with abnormal heart rate or family history of arrhythmia
Common Side Effects
- Fatigue, depression, nausea, dizziness, and insomnia are commonly reported 3
- These symptoms are generally well-tolerated and rarely cause treatment discontinuation
- Drowsiness is one of the most common adverse effects 4
Contraindications
- Heart block (second and third degree)
- Hypersensitivity to propranolol
- Recent or ongoing hypoglycemic episodes
Monitoring and Follow-up
- If treatment is to be discontinued, reduce dosage gradually over a period of several weeks 1
- Regular follow-up is recommended to assess efficacy and adjust dosing as needed
Clinical Pearls
- Propranolol extended-release capsules are not a simple mg-for-mg substitute for immediate-release tablets 1
- Low-dose propranolol (40 mg/day) has shown efficacy in some studies and may be considered in patients who cannot tolerate higher doses 5
- Propranolol has demonstrated better efficacy than some other prophylactic agents in direct comparison studies 4, 6
- While effective for prevention, propranolol has not shown efficacy for treating acute migraine attacks 7
Remember that the goal of migraine prophylaxis is to reduce the frequency, severity, and duration of migraine attacks, thereby improving quality of life and reducing disability.