Propranolol and Flunarizine for Migraine Prophylaxis: Dosage and Usage Guidelines
For migraine prophylaxis, propranolol should be dosed at 80-240 mg per day, while flunarizine is effective at 10 mg daily with a drug-free weekend. 1, 2, 3
Indications for Migraine Prophylaxis
- Preventive therapy should be considered for patients experiencing two or more migraine attacks per month with disability lasting 3 or more days per month 1, 4
- Patients using acute rescue medications more than twice per week 1, 4
- Patients with contraindications to or failure of acute treatments 1, 4
- Presence of uncommon migraine conditions (e.g., hemiplegic migraine, migraine with prolonged aura, migrainous infarction) 1, 4
Propranolol Dosing and Administration
- First-line agent with dosing range of 80-240 mg per day 1, 2
- Start with a low dose and gradually increase to minimize side effects 2
- An adequate trial requires 2-3 months as clinical benefits may not become apparent immediately 1, 2
- Low doses (approximately 1 mg/kg body weight daily) may be effective in many patients, with higher doses reserved for non-responders 5
- Propranolol appears more effective for pure migraine, while amitriptyline may be superior for mixed migraine and tension-type headache 1, 2
Flunarizine Dosing and Administration
- Effective dose is 10 mg daily with a drug-free weekend 3
- A lower dose of 5 mg daily may also be effective for some patients 3
- Flunarizine's effectiveness is comparable to propranolol 160 mg daily 6, 3
- Particularly recommended for children with migraine 7
Side Effects and Monitoring
Propranolol
- Common adverse effects include fatigue, depression, nausea, dizziness, and insomnia 1, 2
- These side effects are generally well-tolerated and rarely cause discontinuation 1
- Beta-blockers with intrinsic sympathomimetic activity (acebutolol, alprenolol, oxprenolol, pindolol) are ineffective for migraine prevention and should be avoided 1, 2
Flunarizine
- Most frequent adverse events are sedation and weight increase 6
- Generally well-tolerated at both 5 mg and 10 mg doses 3
Duration of Treatment and Follow-up
- After initiating prophylactic treatment, continue for 2-3 months to properly assess efficacy 1, 2
- After a period of stability, consideration can be given to tapering or discontinuing the medication 1, 4
- Continuous assessment of efficacy and side effects is recommended 2
Comparative Efficacy
- Propranolol and timolol have the strongest evidence among beta-blockers for migraine prevention 1, 2
- Flunarizine 10 mg daily is at least as effective as propranolol 160 mg daily in reducing migraine frequency 6, 3
- Other first-line options include amitriptyline (30-150 mg/day), divalproex sodium (500-1,500 mg/day), and sodium valproate (800-1,500 mg/day) 1
Clinical Pearls and Pitfalls
- Avoid starting with too high a dose, which can lead to poor tolerability and discontinuation 4
- Inadequate duration of preventive trial (less than 2-3 months) may lead to incorrect assessment of efficacy 1, 4
- Consider combination therapy in refractory cases, as propranolol combined with nortriptyline has shown efficacy and safety 8
- Address comorbidities that may influence treatment selection 4