Propranolol Dosing for Migraine Prophylaxis
For migraine prevention, start propranolol at 80 mg daily and titrate to a target range of 80-240 mg daily, with most patients achieving optimal control at 160 mg daily. 1, 2, 3
Initial Dosing Strategy
- Begin with 80 mg once daily (using extended-release formulation if available) 1, 3
- The FDA label specifies 80 mg as the standard starting dose for migraine prophylaxis 3
- Immediate-release formulations can be divided into 2-3 daily doses, though extended-release once-daily dosing improves adherence 3
Titration and Target Dosing
- The usual effective dose range is 160-240 mg once daily 1, 2, 3
- Increase dosage gradually at 3-7 day intervals until optimal response is achieved 3
- The American Academy of Family Physicians emphasizes that 160 mg daily represents the average optimal dosage for most patients 1, 4
- Maximum recommended dose is 240 mg daily for migraine prevention, though the FDA label notes doses up to 640 mg have been used for hypertension 1, 3
Evidence Supporting Lower Doses
Research demonstrates that approximately 73% of patients respond to low doses (≤1 mg/kg body weight, roughly 40-80 mg daily), suggesting you can start conservatively and avoid unnecessary dose escalation 5. However, guidelines consistently recommend the 80-240 mg range as the evidence-based target 1, 2.
Duration of Trial
- Allow 2-3 months at therapeutic dosing before declaring treatment failure, as clinical benefits may not become apparent immediately 1, 4, 2
- If no satisfactory response is obtained within 4-6 weeks after reaching maximal dose, discontinue therapy 3
Patient Selection Criteria
Propranolol is indicated when patients have:
- Two or more migraine attacks per month with disability lasting 3+ days 1, 2
- Use of acute rescue medications more than twice per week 1
- Failure of or contraindications to acute migraine treatments 1
Important Contraindications and Monitoring
Absolute contraindications include:
- Bradycardia or heart block (second or third degree) 1, 2
- Hypoglycemic episodes 6
- Hypersensitivity to propranolol 6
Monitor for common adverse effects:
- Fatigue, depression, nausea, dizziness, and insomnia 1, 2
- Specifically watch for mood changes and sleep disturbances 1, 2
Critical Pitfall to Avoid
Never use beta-blockers with intrinsic sympathomimetic activity (ISA) for migraine prevention—they are ineffective. 1, 2 Only propranolol and timolol have the strongest evidence for efficacy among beta-blockers 1, 2.
Comparative Considerations
- Propranolol is superior to amitriptyline for pure migraine (without tension-type features) 1, 4
- Amitriptyline (30-150 mg daily) is superior for mixed migraine and tension-type headache 1, 4
- Both are considered first-line agents with equivalent evidence quality 1, 4, 2
Discontinuation
When stopping treatment after achieving stability, withdraw gradually over several weeks, particularly in patients on higher doses, though abrupt cessation is generally safe 3.