Key takeaways:
Propranolol is sometimes used off-label to help with certain kinds of anxiety, such as performance anxiety.
Propranolol can help with physical performance anxiety symptoms, including dry mouth, nausea, fast pulse, or shaky hands.
It’s FDA-approved to treat many other conditions, such as high blood pressure and tremors. It’s also approved to prevent migraines.
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Have you ever felt anxious before a speech or social event? You know what those nerves feel like — your palms get sweaty, your mouth gets dry, your heart starts racing, and you feel like you are going to pass out at any minute.
Propranolol, a medication initially used to treat heart conditions, has been used off-label for years to help with the physical anxiety symptoms you may experience. Musicians, public speakers, and students alike have used propranolol to help calm their nerves. But there are a few things that you should know before getting started.
Below, we’ll dig deeper into what propranolol is, how it works to treat performance anxiety, and what other conditions it may be able to help with.
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What is propranolol?
Propranolol is a non-selective beta blocker, which is a medication that works by blocking beta receptors in many areas of your body. It’s one of the oldest and most widely used beta blockers.
Propranolol was originally designed as a treatment for irregular heart rate or high blood pressure — but its uses have expanded since it was first approved. It’s currently available in a variety of forms, from an injection to an oral tablet.
Can propranolol be used to treat performance anxiety?
Unlike medications like alprazolam (Xanax) or sertraline (Zoloft), propranolol is not technically an anti-anxiety medication. Anti-anxiety medications work by targeting specific areas of the brain, causing you to feel more calm and relaxed. They help stop you from feeling the physical or mental effects of anxiety. Propranolol works a little bit differently — more on this next.
How does it work?
Propranolol can be prescribed off-label as a treatment for specific anxiety types, such as performance anxiety or social anxiety.
Some common physical performance anxiety symptoms include:
Dry mouth
Faster pulse
Nausea
Dizziness
Shakiness in your hands
Sweaty hands
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When you’re feeling stressed or nervous, your body ramps up stress hormone production. These stress hormones attach to beta receptors throughout your body, which may trigger some of the symptoms listed above.
Propranolol works by targeting beta receptors in your body to block the action caused by those stress hormones — ultimately helping to relieve physical anxiety symptoms.
Keep in mind that propranolol doesn’t have any effect on mental anxiety symptoms. You might still feel nervous before giving a speech or attending a social event, but you’re less likely to have those feelings result in a physical reaction.
How effective is it?
There aren’t a lot of studies looking into propranolol use for anxiety. Most research goes back a few decades.
An older study from 1998 compared propranolol to placebo (a pill with no medication in it) for surgical performance anxiety and tremors in five ophthalmology resident physicians. In the study, surgical residents took a propranolol 40 mg pill 1 hour before 40 different surgeries (33 with placebo). The results showed that propranolol significantly lowered anxiety and tremors without any negative effects for the surgeon or the person receiving the surgery.
One 2015 review article suggested that propranolol may work better as a short-term treatment — rather than a long-term treatment — for specific anxiety types (like performance anxiety). This means that daily propranolol use may not have a benefit for conditions like generalized anxiety that usually require ongoing treatment.
How is propranolol taken for performance anxiety?
Propranolol is a prescription medication, meaning you’ll need to talk to your healthcare provider before you use it.
Propranolol may be prescribed off-label for performance anxiety. Typically, you can start to feel the effects of propranolol within a few hours after one dose. Keep in mind that people can react very differently to medications, so you only want to follow the instructions given to you by your healthcare provider.
Like all medications, it may take some time to work out the best dose for you. Your provider may start you on a low dose and adjust based on your level of symptom relief and side effects.
What are the common side effects?
The common side effects for propranolol include:
Feeling tired
Diarrhea
Slower heart rate
Nausea
Dry eyes
What are the serious side effects?
If you are experiencing any serious side effects, call your healthcare provider right away. Call 911 if you feel like your symptoms are life-threatening or if you are having a medical emergency.
Serious side effects can include:
Serious allergic reactions (e.g., hives, itching, swelling of face, rash)
Breathing problems
Propranolol also blocks the physical effects — like fast heart rate and shaking — you’d expect with low blood sugar (hypoglycemia) in diabetes. Because of this, it’s important to be diligent about monitoring your blood sugar while taking this medication, particularly if you have diabetes.
Can propranolol interact with other medications?
Propranolol can interact with other medications or vitamins you may be taking. An interaction is when one substance changes the way another substance works or has a potentially negative effect. This can be harmful and prevent a medication from working well.
Antiarrhythmic medications
Taking propranolol with other medications that affect your heart rhythm may lower your heart rate and blood pressure too much. Examples of these medications include amiodarone, quinidine, and propafenone.
Calcium channel blockers
Using propranolol with calcium channel blockers (CCBs) — like diltiazem — can lead to severely low heart rate or heart failure.
Non-steroidal anti-inflammatory drugs (NSAIDs)
NSAIDs may lessen the blood-pressure lowering effects of propranolol. If you take these medications together, your provider will want to monitor your blood pressure. Examples of NSAIDs include ibuprofen, meloxicam, and ketorolac.
This list does not include all interactions for propranolol. To find out how this drug might interact with something else you are taking, be sure to talk with your pharmacist or other healthcare provider.
What else is propranolol used for?
While propranolol can be prescribed off-label for performance anxiety, it has quite a few approved uses. Below are a few examples.
High blood pressure
Propranolol may be used alone or in combination with other medications, like a thiazide diuretic (water pill), for treating high blood pressure.
A starting dose for high blood pressure is typically 40 mg taken twice per day. When getting started on propranolol, it may take a few days to several weeks to see the medication’s full effects.
Your provider will slowly raise your dose until you achieve target blood pressure control, which is typically 120 mg and 240 mg daily.
Migraine prevention
Propranolol can be used daily for migraine prevention. It’s only approved for prevention and shouldn’t be used to stop a migraine that’s already started.
A common starting dose for migraine prevention is 80 mg per day, broken up into smaller, equal size doses throughout the day. Your provider likely will slowly raise your dose until you’re taking 160 mg to 240 mg daily.
If the medication isn’t working for you after 4 to 6 weeks, your provider may have you stop taking it. In this case, they’ll have you slowly lower your dose over several weeks to avoid side effects from stopping too quickly.
Essential tremor
Essential tremor consists of involuntary, rhythmic movement — usually in the upper limbs. It can have a number of causes, including neurological conditions like Parkinson’s or genetics (inherited). Propranolol is FDA-approved to manage inherited essential tremor.
Propranolol can help lower tremor intensity. A typical starting dose for tremors is 40 mg taken twice per day. Your provider may slowly raise your dose to 120 mg daily.
In addition to these three uses, propranolol is also FDA-approved to treat pheochromocytoma — a rare type of tumor — and a few different heart conditions.
The bottom line
If you need something to help calm your nerves before a big speech or performance, propranolol may be able to help. Propranolol works by blocking beta receptors in the body to lessen anxiety’s physical symptoms, such as dizziness, sweaty palms, or fast pulse.
While propranolol can be used off-label to treat performance anxiety, it has other approved uses, including high blood pressure, migraine prevention, and tremors.
Talk to your healthcare provider if you are experiencing anxiety and have questions about whether propranolol might be able to help you.
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References
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