Propranolol Dosing for Migraine Prophylaxis
The typical dosing regimen for propranolol in migraine prophylaxis is 160-240 mg daily in a once-daily extended-release formulation, with an initial starting dose of 80 mg once daily. 1
Dosing Algorithm
Initial Dosing
- Start with propranolol extended-release 80 mg once daily 1
- For standard (non-extended release) propranolol, a starting dose close to 1 mg/kg body weight daily divided into multiple doses may be effective for many patients 2
Dose Titration
- After initiating therapy, increase the dose gradually at 3-7 day intervals until optimal response is achieved 1
- If no response is seen at the initial dose, gradually increase to the effective dose range of 160-240 mg once daily 1
- Approximately 73.5% of patients may respond to lower doses (around 1 mg/kg/day), while less than one-third of patients will require higher doses 2
Maintenance Dosing
- The usual effective maintenance dose range for migraine prophylaxis is 160-240 mg once daily 1
- If a satisfactory response is not obtained within 4-6 weeks after reaching the maximal dose, propranolol therapy should be discontinued 1
Monitoring and Discontinuation
- Monitor for common adverse effects including fatigue, depression, nausea, dizziness, and insomnia 3
- These side effects are generally well-tolerated and rarely cause treatment discontinuation 3
- If treatment is to be discontinued after a period of stability, gradually taper the medication over several weeks to avoid rebound effects 1
Evidence Strength and Considerations
- Propranolol has consistent evidence supporting its efficacy for migraine prevention at doses of 80-240 mg/day 3
- It is considered a first-line agent for migraine prophylaxis along with timolol, amitriptyline, divalproex sodium, and sodium valproate 3
- Propranolol may be more efficacious in patients with pure migraine, while amitriptyline may be superior for patients with mixed migraine and tension-type headache 3
Special Considerations
- Beta-blockers with intrinsic sympathomimetic activity (acebutolol, alprenolol, oxprenolol, pindolol) are ineffective for migraine prevention 3
- Propranolol is contraindicated in patients with asthma, obstructive airway disease, decompensated heart failure, and second or third-degree heart block 4
- Careful consideration should be given to patients with cardiovascular risk factors before initiating therapy 3
Clinical Pearl
- When switching from standard propranolol tablets to extended-release capsules, do not consider it a simple mg-for-mg substitute as the extended-release formulation produces lower blood levels and has different kinetics 1
- Retitration may be necessary when switching formulations, especially to maintain effectiveness at the end of the 24-hour dosing interval 1