What is the recommended dose of propranolol (beta-blocker) for migraine prevention?

Propranolol Dosing for Migraine Prevention

The recommended dose 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 propranolol dosing for migraine prevention at 80 to 240 mg per day 1
• For extended-release capsules, the FDA-approved dosing starts at 80 mg once daily, with a usual effective dose range of 160-240 mg once daily 2
• Start with a low dose and gradually increase to minimize side effects, with titration occurring over several weeks 1, 2

Administration and Titration

• When using extended-release formulations, dosage may be increased gradually at intervals of 3-7 days until optimal response is obtained 2
• If migraine control is not achieved after 4-6 weeks at the maximum dose, propranolol therapy should be discontinued 2
• When discontinuing therapy, gradually taper the dose over several weeks to avoid potential withdrawal effects 2
• Low doses (approximately 1 mg/kg/day) may be effective for many patients, with only about one-third requiring higher doses 3

Efficacy Considerations

• Propranolol has consistently demonstrated efficacy in reducing migraine frequency 1
• An adequate trial requires 2-3 months as clinical benefits may not become apparent immediately 1
• Propranolol appears more effective for pure migraine, while amitriptyline may be superior for mixed migraine and tension-type headache 1
• Studies have shown significant reduction in migraine frequency with propranolol doses of 120-160 mg daily 4, 5

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 recommended for patients with failure of or contraindications to acute migraine treatments 1

Monitoring and Side Effects

• Common adverse effects include fatigue, depression, nausea, dizziness, and insomnia 1
• Monitor for mood changes and sleep disturbances 1
• Side effects are generally mild but may intensify as the dose increases 3
• Continuous assessment of efficacy and side effects is recommended throughout treatment 1

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 to extended-release formulations, retitration may be necessary as they are not simple mg-for-mg substitutes 2
• Extended-release formulations may require special attention to maintain effectiveness at the end of the 24-hour dosing interval 2

Comparative Options

• Propranolol and timolol are the beta-blockers with the strongest evidence for migraine prevention 1
• Other first-line options include amitriptyline (25-50 mg daily), divalproex sodium, and sodium valproate 1, 6
• Low-dose combination therapy (propranolol 40 mg with nortriptyline) has shown efficacy and safety in some studies 7