Propranolol for Performance Anxiety: What to Know Before Asking Your Doctor

Despite preparing and knowing your material ahead of time, you might still experience performance anxiety—your heart races, your hands tremble, your mouth goes dry, and nothing comes out the way you rehearsed it.

And this physical surge is your body doing exactly what it evolved to do. Your stress system releases adrenaline the moment it senses pressure—even when the threat is nothing more than a boardroom or a concert hall. 

Inevitably, it’d be much nicer to sail through these presentations or performances without anxiety standing in your way. And maybe you’ve started doing your research and have seen propranolol come up again and again. 

Propranolol is a medication that has been used off-label for decades to address physical symptoms associated with performance anxiety. So, how does this performance anxiety medication work? While a provider evaluation is essential to determine if it’s right for you, here’s what you might want to know before having that discussion.

‍

What Is Propranolol?

Propranolol is a non-selective beta blocker. It was first patented in 1962 and has been in clinical use since the mid-1960s, making it one of the oldest and most widely prescribed medications of its kind.

A beta blocker is a medication that blocks beta receptors, which are the docking sites throughout your body where stress hormones, such as adrenaline (epinephrine), attach to trigger a physical response. Thus, when beta receptors are blocked, they may reduce the physical response to these stress hormones.

Propranolol was originally developed and FDA-approved to treat cardiovascular conditions, including high blood pressure, irregular heart rhythms, and certain heart-related problems. 

It’s available in oral formulations and as a low-cost generic medication.

‍

How Propranolol May Help With Performance Anxiety

When you feel anxious or stressed, your body releases adrenaline and norepinephrine. These hormones bind to beta receptors in your heart, blood vessels, and other tissues, contributing to the familiar pounding heart, shaky hands, sweating, flushing, and a trembling voice.

Propranolol works by blocking those receptors. This may reduce certain physical responses to adrenaline, such as an increased heart rate and tremor. 

Propranolol also crosses the blood-brain barrier. But its use in performance-anxiety settings is generally focused on its effects on the body’s physical stress response.

The research has examined these effects, although the overall evidence remains limited. In a small but often-cited 1998 study, five ophthalmology residents took either 40 mg of propranolol or a placebo one hour before performing delicate eye surgery, across 73 procedures. In that small study, propranolol was associated with reduced anxiety and hand tremor, and the researchers reported no observed adverse effect on surgical performance or patient safety. These findings should be interpreted cautiously given the very small number of participants. Broader research has examined propranolol for short-term, situational anxiety, while evidence supporting its routine use for anxiety disorders remains limited.

‍

What Propranolol Does Not Treat

To be clear, propranolol doesn’t directly reduce or stop anxious thoughts.

It may not address the worry, the mental spiral, or the sense of dread. Someone who takes propranolol before a speech may still feel nervous. But the medication may reduce certain physical responses associated with stress and anxiety.

Since propranolol primarily targets physical adrenergic responses and is not FDA-approved as a treatment, it isn’t an appropriate standalone treatment for generalized anxiety disorder (GAD), social anxiety disorder, panic disorder, or any condition where anxiety is persistent and rooted in specific thought patterns.

Simply put: If your anxiety before a presentation is mostly “my heart is racing and my hands won't stop shaking,” a provider may consider propranolol. If it’s mostly “I’ve been catastrophizing about this for three weeks and I can’t turn my brain off,” your provider may recommend a different approach.

Ultimately, a licensed provider can help you figure out what’s best for you.

‍

What the Research Says

Research on propranolol for performance anxiety is limited compared with the deeper body of research behind its cardiovascular uses. Many studies are also not recent and have small sample sizes.

The 2022 review, published in the International Journal of Molecular Sciences, identifies propranolol as one of the few medications with documented use for stage fright—while noting that this indication is considered off-label in most countries. 

Meanwhile, a 2016 systematic review and meta-analysis concluded that the high-quality evidence base for propranolol in anxiety is thinner than its popularity suggests, and called for larger, more rigorous trials.

With that said, propranolol has been used for stage fright by musicians, public speakers, and performers for decades, and anecdotal reports of its benefits are widespread. However, anecdotal use does not establish effectiveness for every person or situation. And this is exactly why a licensed provider is your best resource for your specific situation.

‍

Who May Be a Candidate (And Who Should Not Use Propranolol)

Who may be a candidate: A licensed healthcare provider may consider off-label propranolol for some adults with situational, event-specific performance anxiety, particularly when symptoms are primarily physical, such as a racing heart, trembling, and sweating. Whether it is appropriate depends on the individual’s health history, medications, and other clinical factors.

Who should approach it with caution: Because propranolol acts on the cardiovascular system, it may not be appropriate (or may need careful provider evaluation) for individuals with:

• Asthma or reactive airway disease (since a non-selective beta blocker can trigger bronchospasm, a tightening of the airways)
• Certain heart conditions (including sinus bradycardia, certain heart blocks, cardiogenic shock, or decompensated heart failure)
• Low blood pressure (hypotension)
• Diabetes (propranolol can mask some signs of low blood sugar, which is relevant for anyone on insulin or certain diabetes medications)
• Raynaud’s disease or other peripheral circulation problems
• Pregnancy or breastfeeding (which should be discussed directly with a provider)
• Use of interacting medications (such as other blood pressure drugs, certain antidepressants, or antiarrhythmics)

However, this list isn’t exhaustive. A licensed provider needs to review your full health history before prescribing (if it’s appropriate).

‍

A Note on Off-Label Use

A medication is used off-label when a provider prescribes it for a purpose, population, or dose that isn’t specifically listed in its FDA approval. Propranolol’s use for performance anxiety falls into this category in the US.

In other words, off-label prescribing is permitted in the U.S. when a licensed healthcare provider determines that it is medically appropriate for an individual patient. An off-label use has not been specifically reviewed and approved by the FDA for that indication.

‍

How Propranolol Is Typically Used for Performance Anxiety

For performance anxiety, propranolol may be prescribed for use before a specific triggering event, such as a speech, audition, or exam. Because performance anxiety is an off-label use, the appropriate timing and frequency should be determined by the prescribing healthcare provider.

Generally, there’s no single propranolol anxiety dose that’s suitable for everyone. The 1998 surgical study used 40 mg, but that study dose should not be interpreted as a dosing recommendation. The right amount depends on your specific health history, other medications you may be taking, and your prescribing provider’s clinical judgment. 

Some people report feeling physically steadier with propranolol; however, propranolol may cause side effects including fatigue and dizziness, and individual responses vary.

Your provider can also advise you on whether and how to assess your response before taking it during a high-stakes moment. 

‍

How Propranolol Compares to Other Anxiety Treatments

Here’s how propranolol differs from other common options:

• Benzodiazepines (such as Xanax/alprazolam): Benzodiazepines can cause sedation and may impair concentration, and some carry risks of misuse, dependence, and withdrawal. Propranolol belongs to a different drug class and has a different mechanism and risk profile. Which, if either, is appropriate requires an individual clinical evaluation.
• SSRIs/SNRIs (such as Zoloft/sertraline): These are commonly-used treatments for generalized anxiety, social anxiety, and panic disorders. They’re taken daily and take weeks to reach full effect, meaning they aren’t suitable for situational use.
• Therapy: Cognitive behavioral therapy (CBT) addresses the thought patterns associated with persistent anxiety. But it isn’t necessarily a competitor to propranolol; for some people, short-term medication support alongside therapy is the most effective combination.

‍

Questions to Ask Your Provider Before Starting Propranolol

When bringing up propranolol with your provider, these questions may help guide your conversation:

• Is propranolol appropriate given my current health conditions and medications? (Contraindications and precautions, including bronchial asthma, certain heart conditions, and the potential to mask some signs of low blood sugar, require professional evaluation.)
• What dose and timing would you recommend for my situation?
• Should I try it once before my actual event?
• Is my anxiety mainly situational, or does it point to something that needs a different approach?
• Could it interact with anything else I'm taking?
• What side effects should I watch for? (Common adverse effects reported with some propranolol formulations include fatigue and dizziness; your provider can explain other potential risks and symptoms that require medical attention.)

If getting to an in-person appointment feels like a barrier, you can also connect with a licensed provider online. A virtual visit lets a clinician review your history, determine whether propranolol may be appropriate, and (if applicable) handle the prescription.

And if you’re weighing more than one part of how you feel in your day-to-day, mood and energy support is another area a licensed provider may be able to help you figure out. At Eden, we connect you with a licensed healthcare provider; our process starts with a brief online intake.