Should propranolol (beta blocker) for migraine prevention be taken in the morning or evening?

Timing of Propranolol Administration for Migraine Prevention

Propranolol for migraine prevention can be taken at any time of day—morning or evening—based on patient preference and side effect profile, as the guidelines specify only total daily dosing without time-specific recommendations. 1, 2

Guideline-Based Dosing Recommendations

The established guidelines provide clear total daily dosing but do not mandate specific timing:

• Propranolol is dosed at 80-160 mg daily in long-acting formulations, taken once or twice daily 1
• The American Academy of Family Physicians recommends a broader range of 80-240 mg per day for optimal efficacy 2
• Long-acting formulations allow for once-daily dosing, which improves adherence 1

Practical Timing Considerations Based on Side Effects

Evening dosing may be preferable for most patients because propranolol commonly causes fatigue, which can be better tolerated during sleep hours 2. Key side effects that influence timing include:

• Fatigue and drowsiness are the most common adverse effects, making evening administration logical to minimize daytime impairment 2
• Insomnia can occur in some patients, in which case morning dosing would be more appropriate 2
• Depression and mood changes should be monitored regardless of timing 2

Dosing Strategy and Titration

• Start with a low dose (40-80 mg) and gradually increase to minimize side effects, regardless of whether taken morning or evening 2, 3
• 73.5% of patients respond to low doses (approximately 1 mg/kg body weight daily), so aggressive dose escalation is often unnecessary 3
• Allow 2-3 months for adequate trial before determining efficacy, as clinical benefits may not be immediately apparent 1, 2

Important Clinical Pitfalls

• Avoid beta-blockers with intrinsic sympathomimetic activity, as these are ineffective for migraine prevention 2
• Screen for absolute contraindications including bradycardia, heart block, asthma, cardiac failure, and atrioventricular block before initiating therapy 1, 2
• Monitor for medication-overuse headache if patients continue using acute medications more than twice weekly despite preventive therapy 1

Algorithm for Timing Decision

Choose evening dosing if:

• Patient experiences daytime fatigue or sedation
• Patient has no history of insomnia
• Patient prefers once-daily dosing for adherence

Choose morning dosing if:

• Patient develops insomnia with evening doses
• Patient experiences vivid dreams or nightmares
• Patient has concerns about morning bradycardia