Propranolol Dosing for Daily Migraine Prevention
For daily 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 control at 160 mg once daily. 1, 2, 3
Starting and Titration Strategy
- Begin with 80 mg once daily as the standard initial dose for migraine prophylaxis 1, 3
- Gradually increase the dose at 3-7 day intervals based on response and tolerability 3
- The usual effective maintenance dose is 120-160 mg once daily, though some patients may require up to 240 mg daily 1, 3
- An adequate trial requires 2-3 months at therapeutic dosing before determining treatment failure, as clinical benefits may not become apparent immediately 1, 4
Evidence Supporting Lower Doses
While guidelines recommend 80-240 mg daily, research suggests that many patients respond to lower doses:
- 73.5% of patients responded to doses at or below 1 mg/kg body weight daily (approximately 40-80 mg for most adults), with fewer than one-third requiring higher doses 5
- A study using 40 mg daily showed effectiveness when combined with other agents, though monotherapy at this dose had limited evidence 6
- Starting low and titrating up minimizes side effects while identifying the minimum effective dose for each patient 1, 5
Patient Selection Criteria
Consider propranolol for patients who meet any of these criteria:
- Two or more migraine attacks per month with disability lasting 3+ days per month 1, 2
- Using acute rescue medications more than twice per week 1, 2
- Failure of or contraindications to acute migraine treatments 1, 2
- Pure migraine without tension-type features (propranolol is superior to amitriptyline in this population) 4
Monitoring and Side Effects
- Common adverse effects include fatigue, depression, nausea, dizziness, and insomnia, though these are generally well-tolerated 1, 2
- Monitor for mood changes (particularly depression) and sleep disturbances throughout treatment 1, 2
- Routine cardiovascular monitoring (heart rate and blood pressure) is not required between appointments if the patient is well 1
- The risk of discontinuation due to adverse events is low but increases with higher doses 5, 7
Critical Contraindications
Absolute contraindications include:
Important Pitfall to Avoid
Never use beta-blockers with intrinsic sympathomimetic activity (ISA) for migraine prevention, as they are ineffective 1, 2. Only propranolol and timolol have the strongest evidence for efficacy among beta-blockers 1, 2.
Treatment Duration and Discontinuation
- After achieving a period of stability (usually 2-3 months), consider tapering or discontinuing the medication 2
- Propranolol can be stopped abruptly rather than requiring gradual weaning, though gradual reduction over several weeks may be advisable depending on the patient's age, comorbidities, and dose 3
- Continuous assessment of efficacy and side effects is recommended throughout treatment 1, 2
Comparative Effectiveness
- Propranolol is superior for pure migraine, while amitriptyline may be better for mixed migraine and tension-type headache 1, 4
- Propranolol has moderate certainty evidence for reducing monthly migraine days by approximately 1.27 days versus placebo 7
- The number needed to treat for a 50% or more reduction in monthly migraine days is approximately 6 patients 7