What is the typical starting dose of propranolol (beta blocker) for migraine prophylaxis in an adult patient?

Propranolol Dosing for Migraine Prophylaxis in Adults

For migraine prevention in adults, start propranolol at 80 mg once daily (using extended-release formulation) and titrate to a target range of 80-240 mg daily, with most patients achieving optimal response at 160 mg once daily. 1, 2

Starting Dose and Titration Strategy

• Begin with 80 mg once daily using extended-release propranolol capsules 2
• Increase gradually at 3-7 day intervals based on response 2
• The usual effective dose range is 160-240 mg once daily for migraine prophylaxis 1, 2
• Most patients achieve optimal response at 160 mg once daily 2

Important caveat: Research demonstrates that approximately 73% of patients respond to low doses (around 1 mg/kg body weight daily, roughly 40-80 mg for most adults), so aggressive dose escalation is not always necessary 3. If a patient responds well to 80 mg daily, maintain that dose rather than automatically increasing.

Treatment Duration and Response Assessment

• Allow 2-3 months at therapeutic dose before declaring treatment failure, as clinical benefits may not become apparent immediately 1
• If no satisfactory response is obtained within 4-6 weeks after reaching maximal dose, discontinue propranolol therapy 2
• An adequate trial requires treating 2-3 migraine episodes before abandoning therapy 4

Patient Selection Criteria

Propranolol is appropriate for patients with:

• Two or more migraine attacks per month with disability lasting 3+ days per month 1
• Use of acute rescue medications more than twice per week 1
• Failure of or contraindications to acute migraine treatments 1

Absolute Contraindications

Do not use propranolol in patients with:

• Bradycardia 1
• Heart block (second or third degree) 4
• Hypersensitivity to propranolol 4

Monitoring and Side Effects

• Monitor for fatigue, depression, nausea, dizziness, and insomnia 1
• Specifically assess for mood changes and sleep disturbances 1
• No routine monitoring of heart rate or blood pressure is required between appointments if the patient is well 4

Formulation Considerations

• Extended-release capsules are preferred for once-daily dosing 2
• If switching from immediate-release tablets to extended-release capsules, retitration may be necessary as they are not mg-for-mg equivalent due to different kinetics and lower blood levels 2
• Extended-release formulations produce more sustained therapeutic effect throughout the 24-hour dosing interval 2

When Propranolol May Not Be Optimal

• For patients with mixed migraine and tension-type headache, amitriptyline may be superior to propranolol 1, 5
• For pure migraine without tension features, propranolol is the preferred first-line agent 5
• Beta-blockers with intrinsic sympathomimetic activity (such as pindolol or acebutolol) are ineffective for migraine prevention and should be avoided 1

Discontinuation Strategy

• When stopping treatment, reduce dosage gradually over several weeks depending on the patient's age, comorbidities, and dose 2
• Abrupt discontinuation is possible but gradual tapering is safer to avoid rebound phenomena 4, 2