Propranolol Dosing for Migraine Prophylaxis
The recommended dose of propranolol for migraine prophylaxis is 80 to 240 mg per day, with most patients achieving optimal response at 160 mg daily. 1, 2, 3
Starting Dose and Titration
- Begin with 80 mg once daily (using the long-acting formulation), whether used alone or in combination with other therapies 2, 3
- Gradually increase the dose at 3 to 7-day intervals until optimal response is achieved 3
- The usual effective maintenance dose range is 160 to 240 mg once daily for migraine prevention 1, 2, 3
Evidence for Dose Selection
- Approximately 73.5% of patients respond to low doses (around 1 mg/kg body weight daily or less), meaning many patients will achieve control at 80-120 mg daily 4
- The average optimal dosage appears to be 160 mg once daily, though individual response varies 3
- Doses exceeding 240 mg daily have been studied, but the FDA label notes that if satisfactory response is not obtained within 4-6 weeks after reaching maximal dose, propranolol therapy should be discontinued 3
Duration of Trial
- Allow 2-3 months at therapeutic dose before declaring treatment failure, as clinical benefits may not become apparent immediately 2, 5
- Full hypertensive response (which correlates with vascular effects relevant to migraine) may range from a few days to several weeks 3
Critical Dosing Considerations
- Do not use beta-blockers with intrinsic sympathomimetic activity (acebutolol, alprenolol, oxprenolol, pindolol) as they are ineffective for migraine prevention 1, 2
- If switching from immediate-release propranolol to long-acting formulation, do not use simple mg-for-mg substitution as the kinetics differ and retitration may be necessary 3
- Side effects (fatigue, depression, nausea, dizziness, insomnia) intensify as dose increases, so starting low minimizes discontinuation 1, 4
When to Use This Dose Range
Propranolol at these doses is indicated for patients with:
- Two or more migraine attacks per month causing disability lasting 3+ days 2, 5
- Use of acute rescue medications more than twice weekly 2, 6
- Contraindication to or failure of acute treatments 2, 6
Comparative Context
- Propranolol is more effective for pure migraine without tension-type features 1, 5
- For mixed migraine and tension-type headache, amitriptyline (30-150 mg/day) may be superior 1, 5
- Propranolol and timolol (20-30 mg/day) have the strongest evidence among beta-blockers for migraine prevention 1, 6
Discontinuation
- When stopping treatment, reduce dosage gradually over several weeks to avoid rebound effects, with the tapering period depending on patient age, comorbidities, and dose 3