Beta-Blocker — Migraine Prophylaxis Pregnancy: Should not be given during pregnancy unless its use is essential. There is no evidence of teratogenicity, but beta-blockers reduce placental perfusion, which may result in intrauterine foetal death and immature and premature deliveries; foetal bradycardia and neonatal hypoglycaemia and bradycardia may occur, with an increased risk of cardiac and pulmonary complications in the neonate post-natally. Breast-feeding is not recommended following administration of beta-blockers (section 4.6).

Propranolol (Migraine Prevention)

Brand names: Inderal, Half-Inderal LA

Used in: Headache & Migraine

This entry covers propranolol, a non-selective beta-blocker, used as a first-line oral preventive treatment for migraine.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: Migraine prophylaxis: a starting dose of 40 mg two or three times daily, increased by the same amount at weekly intervals according to patient response; an adequate response in migraine is usually seen in the range 80 to 160 mg/day

Route: Oral

Frequency: Two or three times daily

The SPC groups angina, migraine and essential tremor under the same starting dose (40 mg two or three times daily); the 80 to 160 mg/day response range quoted applies to migraine and essential tremor (angina responds in the range 120 to 240 mg/day). Paediatric migraine (SPC, age-based and NOT per kg): under 12 years — 20 mg two or three times daily; over 12 years — the adult dose. The per-kg paediatric doses that appear in this SPC (0.25 to 0.5 mg/kg three or four times daily; up to 1 mg/kg three or four times daily in Fallot's tetralogy) apply to dysrhythmias, phaeochromocytoma, thyrotoxicosis and Fallot's tetralogy — NOT to migraine. Verify paediatric dosing against a children's formulary. Elderly: use with caution — start with the lowest dose and determine the optimum dose individually by clinical response. Abrupt withdrawal of beta-blockers must be avoided — withdraw gradually over 7 to 14 days, following patients (especially those with ischaemic heart disease) during withdrawal; if beta-blocker therapy is to be stopped before surgery, do so at least 24 hours before the procedure. US labelling gives a different migraine regimen — initial 80 mg daily in divided doses, usual effective range 160 to 240 mg per day, increased gradually, and discontinue (tapering over several weeks) if no satisfactory response within four to six weeks of reaching the maximum dose (openFDA) — verify against the UK SPC.

Dose adjustments

Renal

The half-life of propranolol may be increased in patients with significant hepatic or renal impairment — caution must be exercised when starting treatment and selecting the dose (section 4.4).

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Hypersensitivity to the active substance or to any of the excipients
History of bronchial asthma or bronchospasm (label warning: do not take propranolol if you have a history of asthma or wheezing)
Bradycardia; cardiogenic shock; hypotension; second or third degree heart block; sick sinus syndrome
Uncontrolled heart failure; Prinzmetal's angina
Metabolic acidosis; after prolonged fasting
Severe peripheral arterial circulatory disturbances
Untreated phaeochromocytoma
Patients prone to hypoglycaemia or with restricted counter-regulatory reserves (e.g. malnutrition, prolonged fasting, starvation, chronic liver disease, diabetes, concomitant drugs blocking the response to catecholamines)

Side effects

Bradycardia, cold extremities, Raynaud's phenomenon (common)
Fatigue and/or lassitude, often transient (common)
Sleep disturbances and nightmares (common); hallucinations, psychoses, mood changes, confusion, memory loss, paraesthesia (rare); depression (frequency not known)
Bronchospasm in patients with bronchial asthma or a history of asthmatic complaints, sometimes with fatal outcome (rare)
Heart failure deterioration, precipitation of heart block, postural hypotension which may be associated with syncope, exacerbation of intermittent claudication (rare); dizziness (rare)
Hypoglycaemia, including seizure linked to hypoglycaemia — reported in neonates, infants, children, elderly patients, patients on haemodialysis, patients on antidiabetic therapy, prolonged fasting and chronic liver disease (frequency not known)

Interactions

Calcium channel blockers with negative inotropic effects (e.g. verapamil, diltiazem) — should not be combined; risk of severe hypotension, bradycardia and cardiac failure, particularly with impaired ventricular function or SA/AV conduction abnormalities; neither agent should be given intravenously within 48 hours of discontinuing the other (eMC section 4.4)
Antiarrhythmics — propafenone (additive negative inotropic and beta-blocking effects); quinidine (increases propranolol concentrations, greater beta-blockade, postural hypotension); amiodarone (additive negative chronotropic effect); lidocaine clearance is reduced and lidocaine toxicity has been reported (openFDA)
Digitalis glycosides and other drugs slowing AV nodal conduction — additive slowing of AV conduction and heart rate, increasing the risk of bradycardia (openFDA)
Drugs affecting CYP2D6, CYP1A2 or CYP2C19 pathways — may cause clinically relevant changes in propranolol efficacy and/or toxicity (openFDA)
Hypoglycaemic therapy in diabetes — propranolol may block or modify the signs of hypoglycaemia (especially tachycardia) and may prolong the hypoglycaemic response to insulin; caution with concurrent use (eMC section 4.4)
Note: the eMC section 4.5 text was not captured in the fetched source — verify the full UK interaction list against the current SPC

Clinical monograph

How it works

Its migraine-prophylactic benefit is not fully defined but is attributed to central and vascular beta-adrenergic blockade that reduces neuronal and vascular excitability.

Prescribing in practice

It is contraindicated in asthma and should be used cautiously in other reversible airways disease because non-selective beta-blockade can provoke bronchospasm.
Avoid in uncontrolled heart failure, significant bradycardia or heart block, and use with care in diabetes as it may mask hypoglycaemia.
Do not stop abruptly, as withdrawal can cause rebound and beta-blockers should be tapered.

Monitoring

Monitor heart rate, blood pressure, headache frequency and tolerability, with attention to fatigue, mood and respiratory symptoms.

Counselling the patient

Take regularly for prevention; it does not relieve an acute migraine attack.
Do not stop suddenly, and report wheeze, marked tiredness or a very slow pulse.
Allow several weeks to judge whether attack frequency improves.

Evidence & guidelines

NICE recommends propranolol as a first-line option for the prophylaxis of migraine.

Reference: NICE NG218 (Migraine); Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways