Beta-Blocker — Migraine Prophylaxis Pregnancy: Use with caution — associated with IUGR and neonatal bradycardia; monitor fetus if continued

Propranolol (Migraine Prevention)

Brand names: Inderal, Half-Inderal LA

Adult dose

Dose: 40–240 mg/day in divided doses or as modified-release once daily

Route: Oral

Frequency: Two to three times daily (IR); once daily (LA)

Max: 240 mg/day

First-line oral migraine prophylaxis — NICE recommended. Start 40 mg BD and titrate every 2 weeks. Half-Inderal LA 80 mg once daily is a convenient formulation. Minimum 2–3 month trial before assessing efficacy. Reduces migraine frequency by ~50% in responders.

Paediatric dose

Dose: 0.5–1 mg/day/kg

Route: Oral

Frequency: Two to three times daily

Max: 4 mg/kg/day

Children ≥12 years: 20–40 mg twice daily. Younger children: seek specialist opinion.

Dose adjustments

Renal

No specific dose adjustment required.

Hepatic

Caution — reduced first-pass metabolism in hepatic impairment; increased bioavailability.

Paediatric weight-based calculator

Patient weight (kg)

Children ≥12 years: 20–40 mg twice daily. Younger children: seek specialist opinion.

Clinical pearls

MHRA: do NOT stop abruptly — rebound tachycardia, hypertension, and worsening migraine on withdrawal. Taper over 2–4 weeks.
Useful dual-indication if patient has concurrent hypertension, anxiety, or essential tremor
Contraindicated in asthma — single most important contraindication to remember. Use topiramate or amitriptyline as alternatives in asthmatics.

Contraindications

Asthma or severe COPD
Sinus bradycardia
2nd/3rd degree AV block
Uncontrolled heart failure
Phaeochromocytoma (without alpha-blockade)
Raynaud's syndrome (relative)

Side effects

Fatigue
Cold extremities
Bradycardia
Bronchospasm (avoid in asthma)
Sleep disturbance/nightmares
Depression
Erectile dysfunction
Masking hypoglycaemia

Interactions

Verapamil/diltiazem (severe bradycardia/AV block)
Clonidine (rebound hypertension if propranolol stopped first)
NSAIDs (reduce antihypertensive effect)
Ergotamine (peripheral vasoconstriction — avoid combination in migraine)

Monitoring

Migraine diary (frequency, duration, severity)
Heart rate and blood pressure
Peak flow if history of respiratory disease

Reference: BNFc; BNF 90; NICE NG218 (Migraine); BNFc. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways