Can propranolol (beta-blocker) be used to treat tremors or performance anxiety?

Propranolol for Tremors and Performance Anxiety

Yes, propranolol is highly effective for both essential tremor and performance anxiety, and should be used as first-line therapy for these conditions. 1

Performance Anxiety (Stage Fright)

For situational performance anxiety, prescribe propranolol 20-40 mg taken 1 hour before the performance event. 1 This represents the optimal approach for isolated, infrequent public speaking or performance situations.

Key Clinical Points:

• Propranolol blocks peripheral effects of adrenaline, reducing rapid heart rate, tremors, and nervousness during performance situations 1
• The American College of Cardiology recommends this single-dose strategy specifically for situational use, not chronic daily therapy 1
• Advise patients to trial the dose before an important event to assess individual response and tolerability 1
• Can be combined with cognitive behavioral therapy and relaxation techniques for enhanced outcomes 1

Important Distinction:

• For chronic or frequent performance anxiety, SSRIs/SNRIs are first-line, not beta-blockers 1
• Canadian and Japanese guidelines specifically deprecate propranolol for chronic social anxiety disorder 1
• CBT shows superior outcomes for chronic performance anxiety compared to pharmacotherapy 1

Essential Tremor

Propranolol is the first-line treatment for essential tremor, with effectiveness in up to 70% of patients. 1

Dosing Strategy:

• Start with 30-40 mg daily in divided doses 2
• Can increase to 120-240 mg daily based on response 3, 4
• The 240 mg daily dose shows superiority over lower doses on all assessment methods 4
• Dosage must be individually adjusted for optimal tremor control 2

Evidence Quality:

• Double-blind trials demonstrate improvement in all patients receiving propranolol 120 mg daily 3
• Confirmed by objective measures including grooved pegboard tests and handwriting quality 3
• Long-term effectiveness is maintained without requiring dosage increases 2

Body Part Specificity:

Propranolol is highly effective for upper extremity tremor but has no effect on head tremor 5

• Most pronounced improvement occurs in upper extremities 3
• Head tremor does not respond to propranolol in either essential tremor or dystonia patients 5
• This differential response suggests distinct pathophysiological mechanisms 5

Propranolol vs. Other Beta-Blockers

Propranolol is superior to metoprolol for tremor treatment. 4

• Metoprolol shows no significant tremorolytic effect compared to placebo during prolonged administration 4
• Propranolol (120 mg daily) is better than metoprolol (150 mg daily) based on clinical evaluation and patient self-assessment 4
• In the absence of specific contraindications, propranolol represents the better choice 4
• Metoprolol may be considered as second-line for patients with asthma or reactive airway disease, though it is less effective 1

Surgical Performance and Procedural Tremor

The American College of Surgeons recognizes that surgeons experiencing anxiety during procedures may derive benefit from propranolol, particularly for its heart rate-reducing qualities 6

• Propranolol produces the most advantageous effects among beta-blockers studied 6
• While anxiety doesn't necessarily correlate with increased tremor, the anxiolytic cardiovascular effects can be beneficial 6

Absolute Contraindications

Screen carefully before prescribing propranolol: 1

• Asthma or chronic obstructive pulmonary disease
• Bradycardia or heart block greater than first degree (without pacemaker)
• Decompensated systolic heart failure or cardiogenic shock 6
• Severe hypotension 6

Important Precautions

• Patients with diabetes should use with caution as propranolol may mask hypoglycemia symptoms 1
• Common side effects include bradycardia, hypotension, fatigue, cold extremities, and sleep disturbances 1
• Never abruptly discontinue after regular use due to risk of rebound symptoms 1
• Avoid drugs with SA and/or AV nodal-blocking properties when using propranolol 6

Critical Pitfall to Avoid

Not all beta-blockers are equal for tremor—some can actually worsen it. 7

• Beta-blockers with partial agonist activity (pindolol, labetalol) can induce or exacerbate tremor 7
• These agents should be avoided in patients with tremor 7
• Propranolol, lacking partial agonist activity, is the appropriate choice 1, 3