Propranolol Dosing for Stage/Performance Anxiety
For stage or performance anxiety, take 10-20 mg of propranolol 30-60 minutes before the anxiety-provoking event, with a maximum single dose of 40 mg. 1, 2
Patient Selection
Propranolol works best for performance anxiety when you have prominent physical symptoms rather than purely psychological worry: 1, 2
- Tremor, palpitations, tachycardia, and sweating are the key indicators that propranolol will be effective 1, 2
- This is situational use only—propranolol is not appropriate for chronic daily anxiety treatment 1
- The Japanese Society of Anxiety and Related Disorders specifically notes that while propranolol is ineffective for generalized social anxiety disorder, it is effective for performance anxiety and specific situational triggers with prominent somatic symptoms 1
Mandatory Pre-Treatment Screening
Before taking even a single dose, you must screen for absolute contraindications: 2
- Asthma or reactive airway disease (propranolol can precipitate life-threatening bronchospasm) 2
- Second or third-degree heart block 2
- Decompensated heart failure or significant left ventricular dysfunction 2
- Cardiogenic shock or severe hypotension 2
- Sinus node dysfunction without a pacemaker 2
For as-needed use in healthy patients, the American Academy of Family Physicians states that no routine monitoring is required, but check your pulse before taking propranolol and hold the dose if your heart rate is below 60 bpm 2
Special Warnings for Diabetic Patients
If you have diabetes, propranolol masks the warning symptoms of low blood sugar (hypoglycemia), making it difficult to recognize when your glucose drops dangerously low 1, 2. Use with extreme caution in this population 1.
Timing and Practical Use
- Take the dose 30-60 minutes before the performance or anxiety-provoking event 1
- The immediate-release formulation has a half-life of 3-6 hours, providing coverage for the duration of most performances 1
- This is not suitable for chronic daily use—it's specifically for situational triggers 1
Common Pitfalls to Avoid
Do not combine propranolol with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to excessive bradycardia and heart block risk 2
Monitor for adverse effects including: 2
- Fatigue and dizziness
- Cold extremities
- Bradycardia (slow heart rate)
Evidence Quality Note
While the guideline recommendations are clear and consistent 1, 2, research evidence for exam-related and performance anxiety is actually sparse 3. However, older studies from 1991 support doses of 20-40 mg once to three times daily for anxiety with somatic symptoms 4. The guideline consensus favors the lower end (10-20 mg) for single-dose situational use, with 40 mg as the maximum 1, 2.
Interestingly, one older study found that lower doses (40-80 mg) may actually have greater central effects than higher doses (160-320 mg), suggesting that more is not necessarily better 5.