Propranolol Dosing for Migraine Prophylaxis
The recommended dosage of propranolol for migraine prophylaxis is 80-240 mg per day, with most patients responding to doses in the 160-240 mg range. 1, 2, 3
Dosing Guidelines
Initial Dosing
- Start with 80 mg once daily using extended-release formulation 3
- For immediate-release formulations, divide the total daily dose into multiple administrations
Dose Titration
- Gradually increase the dose at 1-2 week intervals based on response
- If inadequate response after 4 weeks, increase to 160 mg daily
- Further titration up to 240 mg daily may be necessary for optimal migraine control 2, 3
Maintenance Dosing
- Most patients require 160-240 mg daily for effective migraine prophylaxis 2, 3
- Continue effective dose for at least 2-3 months before assessing full benefit
- If satisfactory response is not obtained after 4-6 weeks at maximal dose, consider discontinuing propranolol 3
Efficacy Considerations
- Propranolol has consistently demonstrated efficacy in multiple randomized controlled trials 1
- It is considered a first-line preventive therapy for migraine based on strong evidence
- While some patients may respond to lower doses (around 80 mg daily), studies indicate that many patients require doses of 160-240 mg daily for optimal effect 4
- Suboptimal dosing is a common reason for treatment failure in clinical practice 4
Administration Considerations
- Extended-release formulations allow for once-daily dosing, improving adherence 3
- When switching from immediate-release to extended-release formulations, retitration may be necessary as they are not simple mg-for-mg substitutes 3
- If discontinuing treatment, gradually taper the dose over several weeks to avoid rebound symptoms 3
Monitoring and Safety
Common side effects include:
- Fatigue
- Depression
- Nausea
- Dizziness
- Insomnia 1
Contraindications:
- Asthma or reactive airway disease
- Bradycardia or heart block
- Cardiogenic shock
- Uncontrolled heart failure
Monitor for effectiveness after 2-3 months of therapy at optimal dose 2
Limit use of acute medications to ≤10 days per month to prevent medication overuse headache 2
Clinical Pearl
Beta-blockers with intrinsic sympathomimetic activity (acebutolol, alprenolol, oxprenolol, pindolol) are ineffective for migraine prevention, so specifically use propranolol or other beta-blockers without this property 1.