Should Propranolol Be Continued on the Morning of Elective Surgery for Migraine Prevention?
Yes, propranolol should be continued on the morning of elective surgery, even when taken solely for migraine prevention, to avoid potentially dangerous withdrawal effects including rebound hypertension, tachycardia, and risk of myocardial ischemia. 1, 2
Primary Recommendation
Beta blockers should be continued in patients undergoing surgery who have been on beta blockers chronically, regardless of the indication. 1 This is a Class I recommendation from the 2014 ACC/AHA guidelines, meaning it should be done in all cases. 1
Critical Safety Rationale
The continuation of propranolol is driven by safety concerns rather than perioperative cardiac protection in this population:
Abrupt discontinuation of propranolol can cause exacerbation of angina and, in some cases, myocardial infarction, even in patients without known coronary disease. 2 The FDA drug label explicitly warns that "when discontinuance of propranolol is planned, the dosage should be gradually reduced over at least a few weeks." 2
The risk of rebound blood pressure elevations and coronary ischemia is substantial when beta blockers are stopped perioperatively. 1 This applies even to patients taking propranolol for non-cardiac indications like migraine prevention, as occult coronary artery disease may be unrecognized. 2
Multiple observational studies support the benefits of continuing beta blockers in patients undergoing surgery who are on these agents for longitudinal indications. 1
Practical Implementation
Morning of Surgery Dosing
Administer the patient's usual dose of propranolol on the morning of surgery with a small sip of water. 1
If the patient cannot take oral medications postoperatively due to ileus or NPO status, propranolol can be given intravenously or alternative beta blockers can be administered via IV route. 1
Anesthetic Considerations
Propranolol does not need to be discontinued before surgical anesthesia if it is medically indicated. 3 A retrospective review of 73 patients taking propranolol who underwent non-cardiac surgery found that 72% took propranolol within 24 hours of operation with minimal complications. 3
The impaired ability of the heart to respond to reflex adrenergic stimuli may augment risks of general anesthesia, but chronically administered beta-blocking therapy should not be routinely withdrawn prior to major surgery. 2
Only three episodes of hypotension occurred in the historical series, all responding to decreased anesthetic depth, IV fluids, and in one case a small vasopressor dose. 3
Important Caveats and Monitoring
Contraindications to Consider
While continuation is recommended, be aware of situations requiring extra caution:
Beta-adrenergic blockade may mask signs of acute hypoglycemia (pulse rate and pressure changes), particularly in diabetic patients fasting for surgery. 2
Propranolol may provoke bronchospasm in patients with bronchospastic lung disease, though this is a concern with chronic use rather than a reason to stop acutely. 2
Beta-blockade may mask clinical signs of hyperthyroidism, and abrupt withdrawal could precipitate thyroid storm. 2
Hemodynamic Monitoring
Monitor for bradycardia and hypotension intraoperatively, as the heart's ability to respond to reflex adrenergic stimuli is impaired. 2
Have vasopressors and chronotropic agents readily available if needed. 3
Context: Perioperative Beta Blockade Guidelines
It's important to distinguish this scenario from initiating beta blockers perioperatively:
Starting high-dose beta blockers on the day of surgery in beta-blocker-naïve patients is harmful (Class III recommendation) and associated with increased mortality and stroke risk. 1
However, continuation of existing beta blocker therapy is fundamentally different and carries a Class I recommendation. 1
The POISE trial's negative results (increased mortality and stroke with perioperative metoprolol initiation) do not apply to patients already taking beta blockers chronically. 1
Dosing for Migraine Prevention
For context, propranolol for migraine prevention is typically used at: