What is the recommended dose of propranolol (beta blocker) for migraine prevention?

Propranolol Dosing for Migraine Prevention

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

Initial Dosing Strategy

• Begin with 80 mg once daily using extended-release formulation 1, 2
• Gradually increase the dose at 3-7 day intervals to minimize side effects such as fatigue, depression, and dizziness 1, 3
• The FDA label specifies that the usual effective dose range is 160-240 mg once daily for migraine prophylaxis 2

Target Dosing and Titration

• The optimal therapeutic dose for most patients is 160 mg once daily, though the full range of 80-240 mg/day is supported by guidelines 1, 3, 2
• Approximately 73.5% of patients respond to low doses (around 1 mg/kg body weight daily), meaning many patients will achieve control without needing maximum doses 4
• If inadequate response occurs at lower doses, continue titrating upward within the 80-240 mg range 1, 2

Duration of Trial

• Allow 2-3 months at therapeutic dose before declaring treatment failure, as clinical benefits may not become apparent immediately 1, 3
• The FDA label suggests that if satisfactory response is not obtained within 4-6 weeks after reaching maximal dose, propranolol should be discontinued 2
• However, guidelines recommend the longer 2-3 month trial period for adequate assessment 1

Patient Selection Criteria

Consider propranolol for patients meeting any of these criteria:

• ≥2 migraine attacks per month with disability lasting ≥3 days per month 1, 3
• Using acute rescue medications more than twice per week 1, 3
• Failure of or contraindications to acute migraine treatments 1, 3

Critical Contraindications

Propranolol is absolutely contraindicated in:

• Bradycardia or heart block 1, 3
• Hypoglycemic episodes 1
• Hypersensitivity to propranolol 1

Important Pitfall to Avoid

Never use beta-blockers with intrinsic sympathomimetic activity (ISA) for migraine prevention—they are ineffective. Only propranolol and timolol have strong evidence for efficacy 1, 3

Monitoring Requirements

• Monitor for mood changes, particularly depression, as this is a common adverse effect 1, 3
• Watch for sleep disturbances (insomnia) 1, 3
• Assess for fatigue, nausea, and dizziness 1, 3
• Continuously evaluate efficacy and side effects throughout treatment 1, 3

Comparative Efficacy Context

• Propranolol is more effective for pure migraine, while amitriptyline may be superior for mixed migraine and tension-type headache 1
• Propranolol and timolol are the beta-blockers with the strongest evidence base 1, 3
• Other first-line alternatives include amitriptyline (30-150 mg/day), divalproex sodium, and topiramate 1, 5, 3

Discontinuation Strategy

When stopping propranolol, reduce dosage gradually over several weeks to avoid rebound effects, with the tapering period depending on patient age, comorbidities, and dose 2