What is the typical starting dose of propranolol (beta blocker) for migraine prevention?

Propranolol Dosing for Migraine Prevention

The recommended starting dose of propranolol for migraine prevention is 80 mg per day, with a therapeutic range of 80-240 mg daily. 1, 2

Initial Dosing and Titration

• Start with a low dose and gradually increase to minimize side effects 1
• For the immediate-release formulation, begin with 80 mg daily divided into three doses 2
• For extended-release capsules, start with 80 mg once daily 3
• Titrate the dose gradually over several weeks until optimal migraine prophylaxis is achieved 1, 3
• Some patients may respond to doses as low as 1 mg/kg body weight daily 4

Therapeutic Dosing Range

• The effective dose range for migraine prevention is 80-240 mg per day 2, 1
• For extended-release formulations, the usual effective dose range is 160-240 mg once daily 3
• Clinical benefits may not become apparent for 2-3 months after reaching the target dose 2, 1
• If satisfactory response is not obtained within 4-6 weeks after reaching the maximal dose, consider discontinuing propranolol therapy 3

Administration Considerations

• When using extended-release capsules, administer once daily 3
• When using immediate-release tablets, divide the total daily dose into three equal doses 2
• If switching from immediate-release to extended-release formulations, retitration may be necessary to maintain effectiveness throughout the 24-hour dosing interval 3

Efficacy and Evidence

• Propranolol has strong evidence supporting its efficacy as a first-line agent for migraine prevention 2, 1
• In clinical trials, propranolol has demonstrated significant reduction in migraine frequency compared to placebo 5
• Approximately 73.5% of patients may respond to lower doses of propranolol (around 1 mg/kg/day) 4
• Propranolol appears more effective for pure migraine, while amitriptyline may be superior for mixed migraine and tension-type headache 2, 1

Common Side Effects and Monitoring

• Monitor for common adverse effects including dizziness, nausea, fatigue, depression, and insomnia 2, 1
• These side effects are generally well-tolerated by most patients 2
• Consider gradual withdrawal after a period of stability to avoid rebound symptoms 2, 3

Important Considerations

• Beta-blockers with intrinsic sympathomimetic activity are ineffective for migraine prevention and should be avoided 1
• Propranolol is contraindicated in patients with bradycardia or heart block 1
• If discontinuing treatment, reduce the dose gradually over several weeks to prevent rebound symptoms 3

Alternative First-Line Options

• Other first-line agents for migraine prevention include timolol (20-30 mg/day), amitriptyline (30-150 mg/day), divalproex sodium (500-1,500 mg/day), and sodium valproate (800-1,500 mg/day) 2, 1