Section 02 · Monograph

Propranolol

Reviewed Nov 2026FDA label

InderalBeta-blocker

Indications

Prophylaxis of common migraine headache (both immediate-release and long-acting/extended-release formulations carry this indication)FDA-labeled
Not indicated for treatment of a migraine attack already in progressFDA-labeled
Also FDA-approved for numerous other indications (e.g., hypertension, angina pectoris, cardiac arrhythmias, post-MI mortality reduction, hypertrophic subaortic stenosis, essential tremor, pheochromocytoma) — dosing below is specific to migraine prophylaxisFDA-labeled

Non-selective beta-adrenergic receptor antagonist blocking both beta-1 and beta-2 receptors
The precise mechanism underlying its anti-migraine prophylactic effect has not been established
Beta-adrenergic receptors have been identified in cerebral vasculature; proposed mechanisms include inhibition of catecholamine-induced cerebral vasodilation and modulation of central serotonergic pathways implicated in migraine
Lacks intrinsic sympathomimetic activity; exhibits membrane-stabilizing activity at higher concentrations

Immediate-release: initiate at 80 mg/day in divided doses; effective migraine-prophylaxis dose range is typically 160-240 mg/day in divided doses
Extended-release (long-acting) capsules: initiate at 80 mg once daily; effective range typically 160-240 mg once daily
Titrate gradually to the effective range as tolerated
If a satisfactory response is not obtained within 4-6 weeks after reaching the maximum tolerated dose, therapy should be discontinued
When discontinuing, taper gradually over several weeks; do not stop abruptly

Use caution and consider dose reduction in hepatic impairment given extensive hepatic metabolism

CYP2D6 inhibitors (e.g., fluoxetine, paroxetine, quinidine) increase propranolol plasma levels
Propranolol is also metabolized via CYP1A2 and CYP2C19, creating potential interactions with inhibitors/inducers of those pathways
Calcium channel blockers (e.g., verapamil, diltiazem): additive cardiac depression and increased propranolol concentrations (30-80%)
Theophylline: decreased theophylline clearance (30-52%)
Warfarin: increased warfarin bioavailability/effect; monitor prothrombin time/INR
NSAIDs may blunt the antihypertensive effect of propranolol
Insulin and oral hypoglycemic agents: beta-blockade may mask tachycardia, a key sign of hypoglycemia, and prolong hypoglycemic episodes
Clonidine: risk of exaggerated rebound hypertension if clonidine is withdrawn while the patient remains on propranolol
Rifampin increases propranolol clearance

Cardiovascular: bradycardia, hypotension, exacerbation of heart failure, cold extremities/Raynaud-type peripheral vascular insufficiency
CNS: fatigue, light-headedness, vivid dreams, depression, hallucinations, memory disturbance
GI: nausea, vomiting, diarrhea, constipation
Respiratory: bronchospasm, particularly in patients with reactive airway disease
Dermatologic: rash, and rare reports of Stevens-Johnson syndrome and toxic epidermal necrolysis
Hematologic (rare): agranulocytosis, thrombocytopenic purpura
Sexual dysfunction/impotence

Heart rate and blood pressure at baseline and periodically during titration
Signs/symptoms of heart failure (weight gain, edema, dyspnea)
Respiratory status in patients with reactive airway disease
Blood glucose in diabetic patients, given masking of hypoglycemia symptoms
Hepatic function periodically given extensive hepatic metabolism
Prothrombin time/INR in patients on concurrent warfarin
Clinical response to migraine prophylaxis at 4-6 weeks after reaching the maximum tolerated dose
Taper (do not abruptly discontinue) when stopping therapy

Human data associate propranolol use in pregnancy with intrauterine growth retardation, small placentas, congenital abnormalities, and neonatal bradycardia, hypoglycemia, and respiratory depression
Animal studies at high doses showed embryotoxicity and neonatal toxicity in some species
Use in pregnancy only if the potential benefit justifies the potential risk to the fetus
Propranolol is excreted in breast milk; use caution in nursing mothers and monitor the infant for signs of beta-blockade (bradycardia, hypoglycemia)