Propranolol Dosing for Migraine Prophylaxis
For migraine prevention, start propranolol at 80 mg daily and titrate to a target dose of 120-240 mg daily, with most patients achieving optimal response at 160 mg once daily. 1, 2
Starting Dose and Titration
- Begin with 80 mg once daily (either immediate-release divided doses or extended-release formulation) 1, 2
- Increase gradually at 3-7 day intervals based on response and tolerability 2
- The usual effective dose range is 160-240 mg daily, with 160 mg being the average optimal dose 1, 2
- Maximum studied dose is 240 mg daily for standard prophylaxis, though doses up to 320 mg have been used in some cases 3, 2
Evidence Supporting Low-Dose Efficacy
Interestingly, 73.5% of patients respond to low doses (approximately 1 mg/kg body weight daily), suggesting many patients can be controlled without escalating to maximum doses 4. This is clinically important because side effects intensify with higher doses 4.
Duration of Trial
- Allow 2-3 months at the target dose before determining efficacy, as clinical benefits may not be immediately apparent 1
- If no satisfactory response occurs within 4-6 weeks after reaching maximal dose, discontinue propranolol 2
Critical Selection Point: Beta-Blocker Type Matters
Avoid beta-blockers with intrinsic sympathomimetic activity (acebutolol, alprenolol, oxprenolol, pindolol)—these are ineffective for migraine prevention 3, 1, 5. Only propranolol, metoprolol, timolol, nadolol, and atenolol have demonstrated efficacy 5.
Monitoring and Side Effects
Watch for these common adverse effects 1:
- Fatigue and depression (monitor mood changes closely)
- Sleep disturbances and insomnia
- Nausea and dizziness
- Bradycardia (contraindication if present at baseline) 1
Indications for Starting Prophylaxis
Consider propranolol when patients have 1:
- Two or more migraine attacks per month with disability lasting 3+ days
- Use of acute rescue medications more than twice weekly
- Failure of or contraindications to acute migraine treatments
Formulation Considerations
Extended-release capsules are NOT a simple mg-for-mg substitute for immediate-release tablets—they produce lower blood levels and different kinetics, requiring retitration if switching 2. Extended-release formulations allow once-daily dosing, which may improve adherence 2.
Discontinuation
When stopping propranolol, taper gradually over several weeks rather than abrupt cessation, particularly in patients on higher doses or with cardiovascular comorbidities 2.
Comparative Context
Propranolol has the strongest evidence base among beta-blockers, with 46 controlled trials demonstrating consistent efficacy at 120-240 mg daily 3. It stands as a first-line option alongside amitriptyline (30-150 mg/day) and divalproex sodium, and should be tried before expensive CGRP therapies 5, 6.