Propranolol for Migraine Prevention

This blood pressure medication may help keep debilitating headaches at bay

Propranolol is a beta blocker frequently prescribed to prevent certain types of migraine headaches. Sold under the brand names Inderal and InnoPran, as well as generically, it is considered what's often referred to as an oral migraine prevention medication (OMPM).

OMPMs are drugs that originally were created to treat other conditions but later found to help prevent migraine headaches. Like most such medications, propranolol has potentially intolerable side effects. That said, the American Academy of Neurology rates propranolol as a "level A" drug for migraine prevention, which means it's been found to be highly effective and therefore worth trying.

If you and your doctor are discussing propranolol to help prevent migraine headaches, this overview of how the medication works, how it's taken, its potential side effects, and more will help you to make an informed decision.

How Propranolol Works

As a beta blocker, propranolol primarily is used for cardiac conditions such as high blood pressure, heart rate irregularity, as well as a certain type of kidney tumor. 

The way the drug helps to prevent migraine headaches, experts speculate, is by blocking adrenaline, the hormone that triggers the fight or flight response that arises when we're faced with danger or stress.

Once released into the bloodstream, adrenaline binds to blood vessels surrounding the brain, causing them to constrict. Propranolol and other beta blockers reverse this effect, causing vessels to relax and allowing the free flow of blood to the brain.

Dosing

It's available as an immediate-release tablet or an extended-release capsule. The immediate release tablet should be taken on an empty stomach while the extended release capsule can be taken with or without food (but should be done consistently).

For migraine prevention, a doctor will usually prescribe 20 milligrams (mg) of propranolol three to four times a day to start. The dose then can be gradually increased if necessary to a therapeutic
dose of 160 mg to 240 mgper day. Within four to six weeks, a person should experience a decrease in the number of their migraines by at least half, as well as a reduction in the intensity and duration of their migraine attacks.

The bottom line is that determining whether or not propranolol fails as a migraine preventive drug takes time, at least three months. This is certainly a downside, as those who suffer from migraines often (and understandably) become frustrated with this long waiting period. 

Side Effects

As with any medication, before starting propranolol, it is important to discuss any potential side effects with your doctor. Below are some of the more common side effects seen with propranolol, although for the most part, it is a well-tolerated drug:

  • Fatigue
  • Dizziness
  • Constipation
  • Sleep problems
  • Stomach cramps

Interactions

Since some substances may interfere with propranolol, it's important to tell your doctor about all the medications (both prescription and over-the-counter), supplements, herbals, and vitamins you are taking.

For instance, propranolol significantly increases the levels (up to 70 percent) of the common migraine medications, Zomig (zolmitriptan) and Maxalt (rizatriptan). With that, if you are taking propranolol for migraine prevention and Maxalt for intermittent migraine attacks, you should lower your dose of Maxalt, under the guidance of your doctor.

Contraindications

Propranolol is a pregnancy category C drug so should only be taken if the potential benefit outweighs the potential risk to the baby. Moreover, propranolol is released into breastmilk, so be sure to tell your doctor if you are breastfeeding.

It is unsafe for people with certain health conditions to take propranolol. Some of these conditions include:

  • Cardiogenic shock (Severe heart failure)
  • Second or third-degree heart block
  • An allergy to propranolol

Warnings

If you are taking propranolol, it is essential to take it only as prescribed by your doctor. Stopping propranolol suddenly may cause worsening chest pain (called angina) and in some instances, heart attacks. In order to avoid these serious occurrences, it's important to slowly reduce your dosage of propranolol over at least a few weeks under the guidance of your doctor.

Moreover, propranolol may also mask the signs of an overactive thyroid gland (called thyrotoxicosis), as well as low blood sugar, especially in people with insulin-dependent diabetes.

Besides people with diabetes and thyroid disease, propranolol may not be able to be used (or may need to be more closely monitored) in people with a baseline low heart rate or blood pressure, asthma, depression, or peripheral vascular disease.

Although, considered a well-tolerated and generally safe drug, there are other serious warnings associated with taking propranolol—be sure to review these in detail with your doctor to ensure it's the right drug for you.

A Word From Verywell

Propranolol is a reasonable starting point for most people's migraine prevention journey. Keep in mind, though, that propranolol only works for some people—it's not a magic cure and thus, requires a trial and error process, which can be tedious, Fortunately there are other migraine preventive drug options, including other beta-blockers, non beta-blocking therapies such as the anti-seizure medication Topamax (topiramate), Botox (botulinum toxin type A), and an injectable drug called Aimovig (erenumab)

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