What is the recommended dose of propranolol (beta blocker) for a typical adult patient with migraines and no significant medical history?

Propranolol Dosing for Migraine Prevention

For migraine prophylaxis in adults, start propranolol at 80 mg daily and titrate to a target range of 80-240 mg daily, with most patients achieving optimal control at 160 mg daily. 1, 2, 3

Starting Dose and Titration Strategy

• Begin with 80 mg once daily using the extended-release formulation 3
• Increase gradually at 3-7 day intervals based on response and tolerability 3
• The usual effective dose range is 160-240 mg once daily for optimal migraine prophylaxis 3
• Most patients achieve adequate control at 160 mg daily, though some may require up to 240 mg 1, 2

The FDA label explicitly states that extended-release capsules are not mg-for-mg substitutes for immediate-release tablets due to different kinetics and lower blood levels, so retitration may be necessary if switching formulations 3. The American Academy of Family Physicians guidelines align with this dosing range of 80-240 mg daily as first-line therapy 1, 2.

Duration of Adequate Trial

• Allow 2-3 months at therapeutic dose before declaring treatment failure, as clinical benefits may not become apparent immediately 1, 2
• If no satisfactory response occurs within 4-6 weeks after reaching maximal dose, discontinue propranolol 3
• This extended trial period is critical—many clinicians abandon therapy prematurely 2

Evidence Supporting Lower Doses

While guidelines recommend 80-240 mg daily, research suggests that approximately 73% of patients respond to low doses (≤1 mg/kg/day, roughly 60-80 mg for average adults) 4. However, this conflicts with the more robust guideline recommendations, and given the priority on established consensus guidelines, the 80-240 mg range should be followed 1, 2, 3.

Indications for Initiating Prophylaxis

Propranolol is indicated when patients have: 1, 2

• ≥2 migraine attacks per month producing disability for ≥3 days per month
• Use of rescue medications >2 times per week
• Failure of or contraindications to acute treatments
• Uncommon migraine conditions (prolonged aura, hemiplegic migraine, migrainous infarction)

Absolute Contraindications

Do not use propranolol in patients with: 2

• Bradycardia or heart block (second or third degree)
• Cardiogenic shock or hypotension
• Asthma or severe obstructive airway disease
• Hypersensitivity to propranolol

Critical Safety Considerations

• Never abruptly discontinue after chronic use—taper gradually over several weeks to prevent rebound hypertension, tachycardia, or worsening migraines 2, 3
• Avoid beta-blockers with intrinsic sympathomimetic activity (e.g., pindolol, acebutolol)—these are ineffective for migraine prevention 2
• In diabetic patients, counsel that propranolol may mask hypoglycemia symptoms 5

Common Adverse Effects

Expect and counsel patients about: 1, 2

• Fatigue and dizziness
• Depression and mood changes
• Insomnia
• Nausea
• Weight gain

These side effects are generally well-tolerated but intensify with higher doses 4. No routine monitoring of heart rate or blood pressure is required between appointments if the patient remains asymptomatic 2.

Comparative Effectiveness

• Propranolol is superior for pure migraine, while amitriptyline (30-150 mg daily) is more effective for mixed migraine and tension-type headache 1, 2, 6
• Propranolol and timolol (20-30 mg daily) are the only beta-blockers with strong evidence for migraine prevention 1, 2
• Other first-line alternatives include divalproex sodium (500-1,500 mg daily) and sodium valproate (800-1,500 mg daily) 1