What is the typical dosing regimen for propranolol (beta blocker) in migraine prevention?

Propranolol Dosing for Migraine Prevention

Start propranolol at 80 mg once daily and titrate up to a target range of 80-240 mg daily, with most patients achieving optimal response at 160 mg once daily. 1, 2

Initial Dosing and Titration

• Begin with 80 mg once daily (using extended-release formulation) as the standard starting dose 1, 2
• Gradually increase the dose at 3-7 day intervals to minimize side effects and optimize efficacy 1, 2
• The usual effective dose range is 160-240 mg once daily for migraine prevention 1, 2
• Most patients achieve optimal response at 160 mg once daily, though individual responses vary 2, 3

Evidence for Low-Dose Efficacy

• Approximately 73% of patients respond to low doses (close to 1 mg/kg body weight daily, often 40-80 mg), meaning fewer than one-third will require higher doses 4
• If no satisfactory response occurs within 4-6 weeks at maximal dose (240 mg), discontinue propranolol therapy 2
• An adequate trial requires 2-3 months as clinical benefits may not become immediately apparent 1

Patient Selection Criteria

Consider propranolol for patients meeting any of these criteria:

• Two or more migraine attacks per month producing disability lasting 3+ days 1
• Use of acute rescue medications more than twice weekly 1
• Contraindication to or failure of acute migraine treatments 1
• Presence of uncommon migraine conditions (hemiplegic migraine, prolonged aura, migrainous infarction) 5

Expected Efficacy

• Propranolol produces an average 44% reduction in migraine activity when measured by daily headache recordings, and up to 65% reduction by global patient reports 3
• Propranolol demonstrates consistent evidence of efficacy and is considered a first-line agent alongside timolol (20-30 mg/day) among beta-blockers 5, 1
• For patients with pure migraine, propranolol may be more effective than amitriptyline; however, amitriptyline is superior for mixed migraine and tension-type headache 5, 1

Common Side Effects and Monitoring

Monitor for these frequently reported adverse effects:

• Fatigue, depression, nausea, dizziness, and insomnia are most common but generally well-tolerated 5, 1
• Side effects rarely cause premature withdrawal from treatment 5
• Continuously assess for mood changes (particularly depression) and sleep disturbances throughout treatment 1

Critical Contraindications

Absolute contraindications include:

• Bradycardia 1
• Heart block 1

Important Pitfalls to Avoid

• Never use beta-blockers with intrinsic sympathomimetic activity (acebutolol, alprenolol, oxprenolol, pindolol) as they are ineffective for migraine prevention 5, 1
• When switching from immediate-release propranolol tablets to extended-release capsules, do not use simple mg-for-mg substitution—retitration may be necessary due to different kinetics and lower blood levels 2
• If discontinuing treatment, reduce dosage gradually over several weeks to avoid withdrawal effects, particularly in patients on higher doses 2

Formulation Considerations

• Extended-release capsules allow once-daily dosing and should be the preferred formulation for convenience and compliance 2
• Extended-release formulations produce lower blood levels than immediate-release tablets, requiring careful dose adjustment when switching 2