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

Propranolol Dosing for Migraine Prophylaxis

For migraine prevention, start propranolol at 80 mg once daily and titrate to a target dose of 160-240 mg daily, with most patients achieving optimal response at 160 mg once daily. 1, 2

Initial Dosing and Titration

• Begin with 80 mg once daily (using extended-release formulation) as the standard starting dose for migraine prophylaxis 2
• Increase dosage gradually at 3-7 day intervals until optimal response is achieved 2
• The effective dose range is 160-240 mg once daily, with 160 mg representing the average optimal dosage 1, 2
• Maximum dose should not exceed 240 mg daily for migraine prevention 1

Evidence Supporting Lower Doses

While guidelines recommend 80-240 mg daily, research demonstrates that approximately 73% of patients respond to low doses (≤1 mg/kg body weight daily, roughly 60-80 mg for most adults), suggesting you can start conservatively and avoid unnecessary dose escalation 3. However, the remaining 27% of patients will require higher doses for adequate control 3.

Duration of Trial

• Allow 4-6 weeks at the maximal tolerated dose before declaring treatment failure 2
• An adequate trial requires 2-3 months, as clinical benefits may not become apparent immediately 1
• If no satisfactory response occurs within this timeframe, discontinue propranolol and consider alternative prophylaxis 2

When to Initiate Prophylaxis

Start propranolol when patients meet any of these criteria:

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

Monitoring and Side Effects

• Monitor for fatigue, depression, nausea, dizziness, and insomnia as the most common adverse effects 1
• Check for mood changes, particularly depression 1
• Assess sleep disturbances regularly 1
• Monitor heart rate and blood pressure, particularly in patients with baseline bradycardia or hypotension 1

Critical Contraindications

Absolute contraindications include:

• Bradycardia 1
• Heart block 1
• History of hypoglycemic episodes 1
• Hypersensitivity to propranolol 1

Important Pitfall to Avoid

Never use beta-blockers with intrinsic sympathomimetic activity (such as pindolol or acebutolol) for migraine prevention—they are ineffective for this indication. 1 Only propranolol and timolol have the strongest evidence for migraine prophylaxis among beta-blockers 1.

Discontinuation Strategy

When stopping propranolol, taper gradually over several weeks rather than abrupt cessation, with the tapering period depending on the patient's age, comorbidities, and dose 2. This prevents rebound phenomena and withdrawal symptoms.

Comparative Considerations

• Propranolol is more effective for pure migraine, while amitriptyline may be superior for patients with mixed migraine and tension-type headache 1
• Propranolol is substantially less costly than CGRP antagonists while maintaining similar efficacy 1
• Beta-blockers cause 157 fewer discontinuations per 1000 patients due to adverse events compared with topiramate 1