What is the maximum recommended dose of propranolol (beta blocker) for migraine prophylaxis in an adult patient with no significant medical history?

Maximum Dose of Propranolol for Migraine Prophylaxis

The maximum recommended dose of propranolol for migraine prevention is 240 mg per day, with the usual effective range being 160-240 mg daily. 1, 2

Dosing Strategy and Titration

• Start with 80 mg once daily and gradually increase the dose based on response and tolerability. 1, 2
• The FDA-approved dosing for migraine prophylaxis begins at 80 mg daily, with gradual increases until optimal response is achieved. 2
• Most patients achieve adequate migraine control at 160 mg daily, though some require titration up to the maximum of 240 mg daily. 1
• The American Academy of Family Physicians confirms consistent evidence supporting propranolol at 120-240 mg daily for migraine prevention. 3

Evidence Quality and Strength

• Propranolol has the strongest evidence base among all migraine preventive medications, having been studied in 46 controlled trials. 3
• Both the FDA label and multiple guideline societies (American Academy of Family Physicians, American College of Physicians) converge on the 240 mg maximum dose. 3, 1, 2
• Doses exceeding 240 mg daily have not been established as safe or effective for migraine prophylaxis. 1

Duration of Adequate Trial

• Allow 2-3 months at therapeutic dose before declaring treatment failure, as clinical benefits may not become apparent immediately. 1
• The FDA label specifies that if satisfactory response is not obtained within 4-6 weeks after reaching maximal dose, propranolol therapy should be discontinued. 2

Important Caveats

• Beta-blockers with intrinsic sympathomimetic activity (ISA) are completely ineffective for migraine prevention and must be avoided. 3, 1
• Propranolol is contraindicated in patients with bradycardia or heart block (second or third degree). 1
• Common adverse effects include fatigue, depression, nausea, dizziness, and insomnia—monitor for mood changes and sleep disturbances throughout treatment. 1
• When discontinuing, reduce dosage gradually over several weeks to avoid rebound phenomena. 1, 2

Clinical Context for Lower Doses

• While the maximum is 240 mg daily, research shows that approximately 73% of patients respond to low doses (around 1 mg/kg body weight, often 40-80 mg daily), with fewer than one-third requiring higher doses. 4
• However, for patients with inadequate response to lower doses, titration up to the full 240 mg maximum is appropriate before abandoning propranolol therapy. 1, 2