Is propranolol (beta blocker) effective for chronic migraine prevention?

Propranolol for Chronic Migraine Prevention

Propranolol is recommended for the prevention of migraine, though it has only a weak recommendation for effectiveness in chronic migraine prevention. 1

Efficacy and Evidence

Propranolol is FDA-approved for migraine prophylaxis 2, with the following characteristics:

• Dosage: 160-240 mg once daily for migraine prevention 2
• Mechanism: Prevents chronic sensitization of descending pain control pathways 3
• Evidence strength: Weak recommendation for migraine prevention according to recent guidelines 1
• Comparative efficacy: Non-inferior to topiramate for chronic migraine prevention 4

Treatment Algorithm for Chronic Migraine Prevention

First-Line Options (Stronger Evidence)

1. CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) - Strong recommendation for both episodic and chronic migraine 1, 5
2. OnabotulinumtoxinA - Specifically for chronic migraine 1, 5
3. Topiramate - Recommended for both episodic and chronic migraine 1, 6

Second-Line Options (Including Propranolol)

1. Propranolol (80-240 mg/day) 1, 2
2. Candesartan or telmisartan 1
3. Valproate 1
4. Lisinopril 1
5. Memantine 1

Practical Considerations for Propranolol Use

Dosing

• Starting dose: 80 mg once daily 2
• Titration: Gradually increase dose at 3-7 day intervals 2
• Effective range: 160-240 mg daily for migraine prophylaxis 2
• Lower doses: May be effective in some patients at doses as low as 1 mg/kg/day 7

Monitoring and Expectations

• Allow 2-3 months to assess full efficacy 1, 5
• Use headache diaries to track frequency and severity 5
• Limit acute medications to ≤10 days per month to prevent medication overuse headache 5

Contraindications and Cautions

• Avoid in patients with:
  • Asthma
  • Diabetes
  • Bradycardia
  • Congestive heart failure 1
• Common adverse effects:
  • Lethargy
  • Depression
  • Dizziness
  • Exercise intolerance
  • Hypotension
  • Sleep disorders 1

Special Considerations

Risk of Discontinuation

• Gradual tapering is recommended when discontinuing propranolol to avoid rebound effects 1, 2
• Abrupt discontinuation may exacerbate angina and potentially lead to myocardial infarction 1

Medication Interactions

• May increase warfarin bioavailability and prothrombin time 2
• May decrease the AUC of lovastatin or pravastatin by 18-23% 2

When to Consider Alternative Treatments

Consider switching from propranolol to another preventive medication if:

• Inadequate response after 2-3 months of optimal dosing 5
• Intolerable side effects 7
• Presence of contraindications 1
• Patient has comorbidities better addressed by alternative agents (e.g., depression might favor amitriptyline) 1

While propranolol is an established option for migraine prevention, newer agents like CGRP monoclonal antibodies have stronger recommendations specifically for chronic migraine prevention 1, 5.