Propranolol (Refractory Headache Pathway)

Propranolol regime in headache

Propranolol belongs to the beta-blocker class of medication. Propranolol is used to treat a number of medical conditions. It can be a very effective treatment for migraine.

The dose should be increased gradually as detailed below. If there are no tolerability issues, propranolol can be titrated more rapidly by 20mg - 40mg divided across the doses every week. Continue increasing the dose until it is effective at suppressing the headaches. This is usually 80mg twice daily. The dose can continue to be increased above this to 120mg twice daily if required but should only be done after consultation with your doctor as detailed below. If it is helpful you may be advised to increase this further to 160mg twice daily but this should only be done after consultation with your neurologist.

If you start to get any troublesome side effects please let your General Practitioner (GP) or neurologist know as soon as possible. If tolerability limits making the medication dose increases, your GP can consider switching you to a sustained release preparation and once stable you may have to remain on this but make increases using the 10mg standard release dose.

Dosing Schedule

Side-effects

As with all medications, there are potential side effects and these tend to occur in a small number of patients. The most often reported effects are: nausea, diarrhoea/ constipation, rash, dry eyes, lack of drive or energy, fatigue, coldness of the peripheries with tingling discomfort, dizziness due to low blood pressure (which can cause headaches) and rarely confusion or fainting slowing of the heart rate (bradycardia), sexual dysfunction with erectile difficulties and vivid dreams. Rarely, they can cause loss of hair, low mood and emotional changes. Breathlessness can occur most commonly in patients with asthma or chronic obstructive pulmonary disease.

Contraindications

This drug is contraindicated for patients who have significant heart failure or heart conduction abnormalities (marked bradycardia or 2nd/3rd degree atrio-ventricular block), Prinzmetal’s angina (vasospastic angina), sick sinus syndrome, severe peripheral vascular disease or Raynaud’s disease, asthma requiring steroid based inhalers.

Beta blockers can mask signs of hypo- and hyperglycaemia and ideally should be avoided in patients with diabetes, particularly if they have uncontrolled fluctuations in blood glucose.

Monitoring

A routine heart tracing (ECG) is required for those over 60 years prior to starting treatment.

If the total daily dose of propranolol exceeds 160mg and you have a markedly slow heart rate (bradycardia), of less than 60 beats per minute (bpm), a further ECG should be performed to ensure no significant effects on heart function are consequently occurring.

You should be reviewed by you doctor who may need to start slow medication reduction (with regular ECG review) if you have either a) a slow heart rate of less than 60 bpm with symptoms, or, a heart rate of less than 50 bpm b) a heart rate drop of more than 15 beats per minute from your pre-medication baseline.

If you are known to have diabetes caution is advised, as this can mask awareness of hypoglycaemia and more frequent monitoring of blood glucose should be undertaken.

Interactions

Consider other regular medications you are taking routinely and confirm with your GP or pharmacist that this new medication is compatible. Dosing adjustments or consideration of an alternative medication may be required if an interaction is present.

Risks

Pregnancy and Breast feeding

Propranolol is not recommended if you are pregnant, planning a pregnancy or are breastfeeding. Women of childbearing age should take adequate contraceptive precautions.

This leaflet should be read in conjunction with the product characteristic leaflet that can be found inside all boxes of medication. The use of any medicine is based on considerations of how benefits outweigh potential side effects. Your prescribing doctor will discuss the risks and benefits of the medication as it relates to you and answer any further questions you may have.