Propranolol Dosing for Migraine Prevention

The recommended dosing for propranolol in migraine prevention is 80 to 240 mg per day. 1

Dosing Guidelines and Administration

Propranolol is a first-line agent for migraine prevention with consistent evidence supporting its efficacy 1
Start with a low dose and gradually increase to minimize side effects 1
Dosing should follow this pattern:
- Initial dose: Start at a low dose (40-80 mg/day) 2
- Titration: Increase slowly until benefits are achieved without adverse effects 1
- Target range: 80-240 mg daily for optimal efficacy 1
Long-acting formulations can be used once daily, while standard formulations may require multiple daily doses 3

Propranolol should be considered when patients meet any of these criteria:

Two or more migraine attacks per month with disability lasting 3+ days per month 1
Use of acute rescue medications more than twice per week 1
Failure of or contraindications to acute migraine treatments 1
Presence of uncommon migraine conditions (e.g., hemiplegic migraine, prolonged aura, migrainous infarction) 1

Propranolol has consistently demonstrated efficacy in reducing migraine frequency 1
In FDA documentation, propranolol significantly reduced the headache unit index (composite of frequency and severity) compared to placebo 3
Even low doses (close to 1 mg/kg/day) can be effective in many patients, with approximately 73.5% of patients responding to lower doses 2
Propranolol appears more effective for pure migraine, while amitriptyline may be superior for mixed migraine and tension-type headache 1

Common adverse effects include fatigue, depression, nausea, dizziness, and insomnia 1
These side effects are generally well-tolerated and rarely lead to treatment discontinuation 1
Monitor for:
- Blood pressure and heart rate changes
- Mood changes (depression)
- Sleep disturbances 1

An adequate trial requires 2-3 months as clinical benefits may not become apparent immediately 1
After achieving a period of stability, consider tapering or discontinuing the medication 1
Continuous assessment of efficacy and side effects is recommended 1

Beta-blockers with intrinsic sympathomimetic activity (acebutolol, alprenolol, oxprenolol, pindolol) are ineffective for migraine prevention and should be avoided 1
Propranolol is contraindicated in patients with:
- Bradycardia
- Heart block
- Uncontrolled heart failure
- Asthma or severe COPD 3
Some patients may require higher doses, but increasing the dose may also increase side effects 2
Long-acting formulations (LA) may improve adherence with once-daily dosing 4

Propranolol (80-240 mg/day) and timolol (20-30 mg/day) are the beta-blockers with the strongest evidence for migraine prevention 1
Other first-line options include amitriptyline (30-150 mg/day), divalproex sodium (500-1500 mg/day), and sodium valproate (800-1500 mg/day) 1
Some studies suggest that topiramate (even at low doses of 50 mg/day) may be more effective than propranolol (80 mg/day) in reducing migraine frequency, intensity, and duration 5