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

Propranolol Dosing for Migraine Prevention

The recommended dosage of propranolol for migraine prevention is 80-240 mg per day, with extended-release formulations typically started at 80 mg once daily and titrated up as needed for optimal efficacy. 1, 2

Dosing Guidelines

• Propranolol is a first-line agent for migraine prevention with consistent evidence supporting its efficacy 1
• The American Academy of Family Physicians recommends a dosage range of 80-240 mg per day for migraine prevention 1
• For extended-release capsules, the initial dose should be 80 mg once daily, with a usual effective dose range of 160-240 mg once daily 2
• Dosage should be increased gradually to achieve optimal migraine prophylaxis 2

Titration and Administration

• Start with a low dose and gradually increase to minimize side effects 1
• When using extended-release formulations, dosage may be increased at three to seven-day intervals until optimal response is obtained 2
• If a satisfactory response is not obtained within four to six weeks after reaching the maximal dose, propranolol therapy should be discontinued 2
• It may be advisable to withdraw the drug gradually over several weeks rather than stopping abruptly 2

Duration of Treatment and Efficacy Assessment

• An adequate trial of propranolol requires 2-3 months as clinical benefits may not become apparent immediately 1
• Success rates progressively increase during the entire first year of treatment 3
• Continuous assessment of efficacy and side effects is recommended throughout treatment 1

Indications for Use

• Consider propranolol for patients with two or more migraine attacks per month with disability lasting 3+ days per month 1
• Propranolol should be considered for patients who use acute rescue medications more than twice per week 1
• It is indicated for patients with failure of or contraindications to acute migraine treatments 1

Side Effects and Monitoring

• Common adverse effects include fatigue, depression, nausea, dizziness, and insomnia 1
• Monitor for mood changes and sleep disturbances 1
• Side effects are generally minimal at lower doses but may intensify as the dose is increased 4

Important Considerations and Pitfalls

• 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
• When switching from immediate-release tablets to extended-release capsules, retitration may be necessary as they produce lower blood levels 2
• Low doses (around 1 mg/kg body weight daily) may be effective for many patients, with fewer than a third needing higher doses 4

Comparative Efficacy

• Propranolol and timolol are the beta-blockers with the strongest evidence for migraine prevention 1
• Other first-line options include amitriptyline, divalproex sodium, and sodium valproate 1
• Some studies suggest amitriptyline may be more effective than propranolol for reducing the frequency, length, and severity of migraine episodes 5
• Propranolol appears more effective for pure migraine, while amitriptyline may be superior for mixed migraine and tension-type headache 1