Performance Tremor Medication
For performance tremors (stage fright/performance anxiety), propranolol 20-40 mg taken 1 hour before the performance is the treatment of choice. 1
Mechanism and Rationale
Propranolol, a non-selective beta-blocker, works by blocking the peripheral effects of adrenaline, specifically reducing rapid heart rate, tremors, and nervousness that occur during performance anxiety. 1 This medication has been used for over 40 years with demonstrated efficacy for tremor control and is recommended as first-line treatment by the American Academy of Neurology. 2
Dosing Strategy
- For situational performance anxiety: Take a single dose of 20-40 mg approximately 1 hour before the performance or anxiety-provoking event 1
- This is for acute situational use only, not chronic daily therapy 1
- For chronic essential tremor (if performance tremor is actually essential tremor): The dosage range is 80-240 mg/day 2, 3
Critical Contraindications
Do not prescribe propranolol if the patient has: 1
- Asthma or chronic obstructive pulmonary disease
- Bradycardia or heart block
- Heart failure
- Diabetes (use with extreme caution as it may mask hypoglycemia symptoms)
Common Side Effects to Counsel About
Patients should be warned about: 1
- Bradycardia and hypotension
- Fatigue and cold extremities
- Sleep disturbances
- Never abruptly discontinue after regular use due to risk of rebound symptoms
Alternative Beta-Blockers
If propranolol is not tolerated, other beta-blockers with evidence for tremor control include: 2, 3
- Nadolol (40-320 mg daily)
- Metoprolol (25-100 mg extended release)
- Atenolol (limited evidence)
- Timolol (20-30 mg/day)
Non-Pharmacological Adjuncts
Propranolol should be combined with: 1
- Cognitive behavioral therapy
- Relaxation techniques
- Adequate preparation and practice
Lifestyle modifications to recommend: 3
- Avoid strenuous exercise before precision tasks
- Reduce caffeine consumption
- Implement stress reduction techniques
Special Populations
- Elderly patients: Use caution as excessive heart rate reduction may lead to serious adverse events 2
- Patients with hypertension: Beta-blockers may provide dual benefits for both tremor and blood pressure control 2, 3
- Women of childbearing age: If considering primidone as an alternative, counsel about teratogenic risks 2
When Performance Tremor May Actually Be Essential Tremor
If tremor occurs beyond performance situations or fails to respond to situational propranolol, consider that this may be essential tremor requiring: 2
- Regular daily propranolol (80-240 mg/day) or primidone as first-line therapy
- These medications are effective in up to 70% of essential tremor patients
- Second-line options include gabapentin or carbamazepine
Surgical Options for Refractory Cases
If medications fail due to lack of efficacy, side effects, or contraindications, consider: 2, 3
- Deep brain stimulation (DBS)
- Magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy, which shows 56% sustained tremor improvement at 4 years with lower complication rates (4.4%) compared to DBS (21.1%)