Propranolol Dosing for Migraine Prevention
The starting dose of propranolol for migraine prevention is 80 mg once daily, with a recommended effective dose range of 160-240 mg once daily. 1, 2
Initial Dosing and Titration
- Start with 80 mg propranolol once daily as the initial dose for migraine prevention 1, 2
- Gradually increase the dose at intervals of 3-7 days to minimize side effects and achieve optimal response 2, 1
- The usual effective dose range is 160-240 mg once daily for optimal migraine prophylaxis 2, 1
- If using extended-release formulation, maintain once-daily dosing schedule 1
Efficacy Considerations
- Propranolol is a first-line agent for migraine prevention with consistent evidence supporting its efficacy 2, 3
- An adequate trial requires 2-3 months as clinical benefits may not become apparent immediately 2
- Recent meta-analysis shows moderate certainty evidence that propranolol increases the proportion of patients who experience a 50% or more reduction in monthly migraine days compared to placebo 3
- Propranolol appears more effective for pure migraine, while amitriptyline may be superior for mixed migraine and tension-type headache 2
Administration Guidelines
- When switching from immediate-release to extended-release formulations, retitration may be necessary as they have different kinetics and produce lower blood levels 1
- If satisfactory response is not obtained within 4-6 weeks after reaching the maximal dose, consider discontinuing propranolol therapy 1
- Some patients may respond to lower doses (around 1 mg/kg body weight daily), though most will require the standard recommended range 4
Monitoring and Side Effects
- Common adverse effects include fatigue, depression, nausea, dizziness, and insomnia 2
- Monitor for mood changes and sleep disturbances during treatment 2
- High-quality evidence shows propranolol increases the proportion of patients who discontinue due to adverse events compared to placebo, though the overall tolerability profile is acceptable 3
Important Considerations
- Beta-blockers with intrinsic sympathomimetic activity are ineffective for migraine prevention and should be avoided 2
- Propranolol is contraindicated in patients with bradycardia or heart block 2
- If discontinuation is necessary, gradually reduce the dose over several weeks to avoid rebound symptoms 1, 2
- Propranolol and timolol are the beta-blockers with the strongest evidence for migraine prevention 2, 5