Propranolol For Anxiety: Can Beta-blockers Help?

By Sarah Malka, MD
Medically reviewed
August 2, 2021

More than 40 million adults and roughly 5 million children suffer from an anxiety disorder.

For these people, the normal feelings of anxiety—physical and emotional reactions to stressful, dangerous, or intense circumstances—don’t just pass away normally.

People suffering from anxiety disorders can often experience these stress responses long after the stressful situation ends, and sometimes have these anxiety symptoms even when there isn’t a stressful situation at all.

These symptoms interfere with their relationships, work, and daily life and activities.

Common anxiety disorders include generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and social anxiety disorder.

Fortunately, there are treatments that can help. Prescription drugs like antidepressants, buspirone, and benzodiazepines are FDA-approved for the treatment of anxiety.

But not all anxiety is the same. Some people experience anxiety only in specific stressful situations, or have a dramatic physical response to stressful events—symptoms like sweating, flushing, a racing heart, nausea, chest tightness, and shortness of breath.

For patients with these symptoms who suffer from performance anxiety, stage fright when public speaking, or other specific social phobias, healthcare professionals will sometimes prescribe propranolol off-label.

Propranolol (Inderal) is a beta-blocker most often used to treat heart conditions like irregular heartbeat and high blood pressure.

It can decrease the risks of heart attack and stroke, and prevent angina (heart-related chest pain). It is also sometimes used to prevent migraine headaches.

When prescribed off-label to patients who struggle with stage fright or social phobia, propranolol helps calm the physical symptoms they experience.

It slows a patient’s racing heart and alleviates shakiness, sweating, and other uncomfortable symptoms.

In this article, I’ll explain what propranolol is, what the drug is used to treat, and how it works for those conditions and for anxiety.

I’ll also discuss the potential side effects of propranolol, and who should avoid beta-blockers. Finally, I’ll explain how propranolol is taken, its dosages, and warnings for drug interactions that may occur when taking this medication.

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What is Propranolol?

Propranolol is one of a class of prescription medications called beta-blockers (beta-adrenergic blocking agents). It works by changing the way your body responds to stress hormones.

Typically, when you begin to feel anxious, your body produces stress hormones like epinephrine (adrenaline) and norepinephrine (noradrenaline).

This is known as the “fight or flight” response. These hormones increase your heart rate and blood pressure, priming you to act if something dangerous occurs.

This hormonal response to stress or fear can produce an array of physical symptoms like shakiness, shortness of breath, palpitations, chest tightness, flushing, muscle tension, excessive sweating, nausea, and dilated pupils. 

When you take propranolol, it decreases the effects of those stress hormones.

It blocks how epinephrine and noradrenaline work on the beta receptors on your cells, reducing the physical effects of anxiety.

This can help you maintain a normal heart rate and blood pressure, and feel less shaky and nauseous, even when facing a situation that might otherwise trigger your anxiety.

What Does Propranolol Treat?

Propranolol was initially developed more than a half-century ago to treat angina pectoris (cardiac chest pain).

Over the years, healthcare professionals have found several other uses for the medication.

Today, healthcare providers use the prescription drug to treat: 

  • Angina (chest pain)
  • Myocardial infarction (heart attack)
  • Hypertension (high blood pressure)
  • Cardiac arrhythmias (heart palpitations) 
  • Thyroid conditions (hyperthyroidism)
  • Migraine
  • Tremor
  • Pheochromocytoma (adrenal tumors)

Although propranolol is not FDA-approved to treat mental health disorders, some physicians will prescribe it off-label to treat anxiety patients.

Unlike other anxiety medications like Xanax or antidepressants that influence the emotional centers of the brain, propranolol offers relief by helping to block the physical effects of anxiety.

How Does Propranolol Work? 

Propranolol is a beta-blocker, a class of prescription drugs that affects how your body responds to stress hormones like epinephrine (adrenaline) and norepinephrine (noradrenaline).

Other beta-blockers include: 

  • Acebutolol (Sectral)
  • Atenolol (Tenormin)
  • Bisoprolol (Zebeta)
  • Metoprolol (Lopressor, Toprol XL)
  • Nadolol (Corgard)
  • Nebivolol (Bystolic)

Some beta-blockers target the heart and blood vessels, while others only target the heart.

All of them lower heart rate, reduce blood pressure and improve blood flow throughout the body.

How Propranolol Helps With Anxiety 

Propranolol is not FDA-approved to treat anxiety, but some healthcare providers will prescribe it off-label for patients with specific social phobias around performance, public speaking, or other short-term events.

Healthcare providers will also use it to help people who experience panic attacks or have post-traumatic stress disorder (PTSD).

What does off-label mean?

When a healthcare provider prescribes a medication off-label, it means that they are taking a drug that has been FDA-approved to treat one type of condition and using it to treat another.

The practice is common, legal, and medically ethical, as long as the doctor uses their professional judgment when they recommend the treatment. By some estimates, roughly 20% of prescriptions written today are for off-label use. 

Do beta-blockers help with performance anxiety? 

Propranolol treats anxiety by targeting the physical effects of the disorder. It is useful when patients experience short-term anxiety around specific social events like public speaking and public performance.

Many professional musicians and other performers rely on a dose of propranolol before going on stage to alleviate the sweating, shakes, and other symptoms of anxiety they would otherwise experience.

Side Effects

Healthcare professionals consider propranolol to be both safe and effective.

Side effects are mild for most patients. The most common side effects of the medication are: 

A small percentage of patients experience more serious side effects when taking propranolol.

If you are using the medication and begin to experience chest pains, persistent insomnia, sinus problems, hallucinations, difficulty breathing, a resting heart rate below 50 bpm, or fluid retention in your legs and ankles, seek medical advice right away. If left untreated, a poor reaction to propranolol can result in kidney disease, kidney failure, heart failure, and death.

Allergic reactions to propranolol are rare, but if you develop hives, itchy or peeling skin, wheezing, unusual hoarseness, swollen lips, tongue, mouth, or face while taking the drug, seek medical attention immediately.

Who Should Avoid Beta-blockers?

Propranolol is not for everyone. Before you take the drug, tell your doctor if you have:

  • Advanced heart failure
  • Asthma
  • Diabetes
  • Hypertension (if you are over age 60)
  • Low blood pressure
  • Slow heart rate 

If you have one of these conditions, you may still take propranolol, but there are more risks.

Your healthcare provider may need to adjust your dosage or talk through the costs and benefits before starting your new medication regimen.

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How to Take it

Propranolol is available as an oral tablet, oral extended-release capsule, and oral solution under different brand names. If you are suffering from anxiety, providers will usually prescribe the medication in its tablet form.

You can take propranolol with or without food. Most people use propranolol as needed, just before a stressful or anxiety-provoking event. Others take it every day if they have frequent bothersome physical symptoms of anxiety.

Dosages

Propranolol is available in a variety of dosages to meet different patient’s needs. For many anxiety sufferers, the dosage is 40 mg, once per day, but your dosage needs may be different depending on when you feel anxiety, if your anxiety is performance-based, and other factors.

Your healthcare provider will prescribe the appropriate amount of medication for your condition, age, and overall health. 

Warnings

Take your propranolol medication as directed. Otherwise, the drug can affect heart function in dangerous ways.

If you are taking propranolol daily for blood pressure or for your heart, never stop taking propranolol without talking to your provider first.

Abruptly discontinuing the drug can adversely affect your heart’s rhythm and blood pressure, or cause chest pain and even heart attack. If you would like to stop taking your medication, your healthcare provider can help you discontinue it safely. 

Drug Interactions

Your healthcare provider should know what other prescriptions, over-the-counter medications, and homeopathic treatments you regularly take before you begin using propranolol.

That way, they can manage your dosage and help you avoid any adverse drug interactions.

Tell your doctor about all medications, supplements, and remedies that you take.

Be particularly careful about taking propranolol if you are taking:

  • Acebutolol
  • ACE inhibitors
  • Alpha-blockers 
  • Antiarrhythmic drugs
  • Atenolol
  • Bisoprolol
  • Calcium channel blockers
  • Carteolol
  • Dobutamine 
  • Epinephrine
  • Esmolol
  • Isoproterenol
  • Metoprolol
  • Nadolol
  • Nebivolol
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) 
  • Sotalol
  • SSRI antidepressants
  • Theophylline
  • Warfarin

You may also want to avoid caffeine or high potassium foods while taking propranolol. Caffeine and other stimulants can make propranolol less effective. Propranolol may also make high potassium foods harder to digest.

You can start controlling your anxiety and get access to the treatment you need with K Health. Starting at $12/month, get prescriptions for mental health medications plus unlimited provider visits through the K Health app. Start your free assessment here.

K Health articles are all written and reviewed by MDs, PhDs, NPs, or PharmDs and are for informational purposes only. This information does not constitute and should not be relied on for professional medical advice. Always talk to your doctor about the risks and benefits of any treatment.

Sarah Malka, MD

Dr. Sarah Malka is a board certified emergency medicine physician with K Health. She completed her residency at Harvard Medical School.