What is the recommended dose of propranolol (beta blocker) for migraine prophylaxis in children?

Propranolol Dosing for Migraine Prophylaxis in Children

The recommended dose of propranolol for migraine prophylaxis in children is 3 mg/kg/day, which has been shown to be effective in controlled clinical trials. 1

Dosing Guidelines

• Initial starting dose should be 1 mg/kg/day divided into three doses to minimize side effects and allow for tolerance assessment 2, 1
• Gradually increase to the target maintenance dose of 2-3 mg/kg/day 2, 1
• Maximum effective dose is typically 3 mg/kg/day, with limited evidence supporting higher doses 2, 1
• For children with poor initial response, the dose can be increased up to 3 mg/kg/day 2
• Minimum time interval between dose increases should be 24 hours to monitor for potential adverse effects 2

Efficacy Considerations

• A randomized controlled trial demonstrated that propranolol at 3 mg/kg/day reduced headache frequency by more than 50% in 83% of pediatric patients 1
• The mean headache frequency per month was significantly reduced from 13.86 ± 2.11 to 4.23 ± 3.24 with propranolol treatment 1
• Some children may respond to lower doses, with evidence showing that doses close to 1 mg/kg/day can be effective in approximately 73.5% of patients 3
• Complete cessation of headache attacks occurred in 14% of patients treated with propranolol 1

Administration Guidelines

• Propranolol should be administered with food to reduce the risk of hypoglycemia 2
• The total daily dose should be divided into three doses for optimal efficacy and to minimize side effects 2, 1
• Treatment duration should be at least 2-3 months to properly assess efficacy 1, 4

Monitoring and Safety

• Monitor heart rate and blood pressure before initiating treatment and at follow-up visits 2
• Common side effects include drowsiness, fatigue, and sleep disturbances, which are generally well-tolerated in children 5, 1
• Propranolol should be temporarily discontinued during periods of reduced oral intake or illness 2
• Contraindications include sinus bradycardia, hypotension, heart block greater than first degree, heart failure, and reactive airways disease 6

Special Considerations

• For children with comorbidities that increase the risk of hypoglycemia, consider starting at a lower dose of 0.5 mg/kg/day 2
• Children with asthma or reactive airway disease should avoid propranolol due to the risk of bronchospasm 6
• Younger children (under 8 weeks of age) may require more cautious dosing and monitoring 6, 2

Treatment Alternatives

• If propranolol is ineffective or poorly tolerated, alternative prophylactic options include flunarizine (5 mg/day) and pizotifen (0.5-1.5 mg/day) 5
• Topiramate at a dose of 3.5 ± 1.7 mg/kg/day has also shown efficacy in children with migraine refractory to other prophylactics 7