Propranolol Dosing for Migraine Headaches
The recommended dose of propranolol for migraine prophylaxis is 160-240 mg once daily using the extended-release formulation, with treatment typically initiated at 80 mg once daily and gradually increased to achieve optimal response. 1, 2
Dosing Regimen
Initial Dosing
- Start with 80 mg propranolol extended-release capsules once daily 2
- Titrate dosage gradually at three to seven-day intervals until optimal response is obtained 2
Maintenance Dosing
- Effective dose range: 160-240 mg once daily 1, 2
- Maximum dose: 240 mg daily (doses exceeding this have not been established for safety in migraine) 2
Duration of Treatment
- Evaluate efficacy after 4-6 weeks of treatment 1
- Continue effective prophylactic treatment for at least 3-6 months before attempting discontinuation 1
- If discontinuing, gradually taper over several weeks to prevent withdrawal symptoms 1, 2
Clinical Considerations
Efficacy Assessment
- If satisfactory response is not obtained within 4-6 weeks after reaching the maximal dose, propranolol therapy should be discontinued 2
- The American Academy of Neurology recommends propranolol as a first-line agent for migraine prophylaxis 1
Important Caveats
- Propranolol is for prophylaxis only, not for treating acute migraine attacks 3
- When switching from immediate-release propranolol tablets to extended-release capsules, retitration may be necessary to maintain effectiveness throughout the 24-hour dosing interval 2
- Extended-release capsules are not a simple mg-for-mg substitute for immediate-release tablets due to different kinetics and lower blood levels 2
Alternative Approaches
- For patients who cannot tolerate higher doses, some evidence suggests that lower doses (approximately 1 mg/kg daily) may be effective in some patients 4
- Consider combination therapy with other preventive medications in patients with inadequate response to monotherapy 5
Monitoring
- Monitor for common side effects: fatigue, dizziness, sleep disturbances, and bradycardia
- Regular follow-up is recommended to assess efficacy and adjust dosing as needed
- If treatment is to be discontinued, reduce dosage gradually over a period of several weeks 2
Remember that propranolol is specifically for migraine prevention and will not abort an acute migraine attack. For acute treatment, consider NSAIDs, triptans, or combination therapy as recommended by current guidelines 1.