Beta-Blockers Can Calm Performance Anxiety. But They Don’t Work for Everyone

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<p>Until two years ago, 40-year-old Michelle Jewell had never felt stage fright. She grew up performing music and acting in plays, and for most of her career, frequently gave public presentations or speeches. Then, seemingly overnight, something changed. Jewell was diagnosed with generalized anxiety disorder, which — amid strain in her relationship and stress at her job as a communications manager at a federally funded research center — began to manifest as stage fright. </p>
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<p>Before stepping up to speak, Jewell would notice her fitness tracker recording heart rates of 160-170 beats per minute (a normal heart rate is typically 60-100 beats per minute). She says she would hyperventilate and feel so nauseous that she lived in fear of having to go on stage. Her ease with being in the limelight had always felt like a superpower, but “suddenly, my superpower was just kind of gone,” Jewell says. </p>
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<p>She discussed the issue with her therapist, who suggested she try a medication called propranolol to ease her anxiety around public speaking. When she took a dose before her next presentation, Jewell noticed that her heart did not race quite as much, nor was she nauseous or struggling to catch her breath. </p>
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<p>“I felt more comfortable,” Jewell recalls. “I was able to fully be present in this keynote that I was giving.”</p>
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<p>Her general anxiety has dipped since then, and so has her anxiety about public speaking. Jewell says she no longer needs the propranolol for every presentation, but says it continues to help her keep up with the demands of her job at a difficult time in her life. “Once you have an anxiety loop like that, it can be so hard to get yourself out of it,” she says. </p>
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<h2 class="wp-block-heading">A Drug for the Heart, Repurposed for the Mind</h2>
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<p>Propranolol was developed and is FDA-approved to treat cardiovascular conditions such as high blood pressure and angina (a type of chest pain caused by insufficient blood flow to the heart). It belongs to a class of medications known as beta-blockers, which work by reducing the heart’s responsiveness to adrenal hormones. </p>
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<p>These same hormones can also drive a racing heart before a speech or performance, and clinicians have found that beta-blockers can ease that symptom as well, even though they’re not approved for that use. Propranolol is approved for certain other non-cardiovascular conditions, such as migraine prevention, restless legs syndrome, and essential tremor. </p>
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<p>Their use for stress-free performances has gained increasing attention: <a href="https://www.hollywoodreporter.com/news/general-news/little-pill-awards-season-1236366170/">various celebrities have name-checked beta-blockers</a> at the Oscars, Golden Globes, and SAG Awards, and the pills are often <a href="https://www.tiktok.com/@karenpluscats/video/7546828397205409055">touted on </a>TikTok as a magical <a href="https://www.tiktok.com/@pharmacistdom/video/7605416428933582094">confidence booster</a>. Over the past decade, as online pharmacies and telemedicine have proliferated, propranolol has become widely available through near-instant prescriptions on platforms that actively promote it as a “magic pill” to address anxiety.</p>
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<p>Many small studies have shown that beta blockers benefit people who experience performance anxiety, which is a subset of social phobia. But there has never been a large-scale, randomized trial to test their effectiveness. A <a href="https://pubmed.ncbi.nlm.nih.gov/39271062/">2024 analysis</a> of existing peer-reviewed literature notes a lack of clinical guidance for prescribing them for anxiety. The authors highlight that while beta blocker prescriptions for anxiety rose from 2003 to 2018, the evidence supporting their effectiveness in treating the condition is scant.</p>
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<p>“This is one area where the amount of non-clinical trial evidence is quite large,” says <a href="https://www.columbiapsychiatry.org/profile/franklin-r-schneier-md">Franklin Schneier, M.D.</a>, a psychiatrist at Columbia University in New York. “The downside is that we have weaker clinical experience, which is often convincing to clinicians but not always super-reliable.” </p>
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<h2 class="wp-block-heading">What Beta-Blockers Actually Do, and Why They Help</h2>
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<p>Shaky hands, sweaty palms, or a thundering pulse are all typical physical responses to nerves before a performance. While these symptoms are common in the general population, performance anxiety, a form of social anxiety, is estimated to seriously affect up to a third of performing artists and athletes. </p>
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<p>Hints that a beta-blocker named propranolol could quiet these symptoms first emerged as early as 1965, when researchers found that the drug could provide relief to people with thyrotoxicosis, a condition where high levels of thyroid hormones can cause symptoms of anxiety. Later, studies in musicians, athletes, surgeons, and people undergoing surgery found that beta-blockers eased the pre-performance jitters brought on by the adrenaline (epinephrine) rush that precedes an important event. </p>
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<p>That flood of adrenaline helps the body respond quickly in the moment by increasing heart rate and breathing. But a racing pulse, hyperventilation, shaky hands, or a trembling voice can be detrimental to performance. “For some people with performance anxiety, these physical manifestations really are the most disturbing thing,” explains Dr. Schneier. “They're focusing on their heart racing instead of focusing on what they need to do.” </p>
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<p>“For some people with performance anxiety, these physical manifestations really are the most disturbing thing. They're focusing on their heart racing instead of focusing on what they need to do.” </p>
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<p>Beta-blockers bind to adrenergic receptors on cells to tamp down cues from adrenaline and norepinephrine, lowering a person’s heart rate to manageable levels — as Jewell noticed on her fitness tracker. </p>
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<p>But when anxiety is more cognitive, such as worrying about saying the wrong thing during a presentation, the drugs may offer little relief. </p>
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<h3 class="wp-block-heading">Weaker Efficacy for Cognitive Anxiety</h3>
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<p>Thirty-nine-year-old Rebecca Kaplan was diagnosed with anxiety as a teenager and had been on medication for it since then. Early in her career, the prospect of doing a public-facing presentation at work exacerbated her symptoms. Her doctor suggested a beta-blocker, but the medication did not relieve Kaplan’s situational panic, which caused her to grow sweaty, shaky, and agitated (she did not hyperventilate or experience a racing heart).</p>
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<p>Over the years, different psychiatrists continually suggested she try beta blockers to ease the anxiety, but they made no difference. “I was kind of hoping that they would be a useful tool,” Kaplan says. “It felt like something that could be an easy part of my day-to-day life. But it just wasn't for me.”</p>
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<p>As far back as 1987, researchers reviewing the literature on propranolol <a href="https://www.sciencedirect.com/science/article/abs/pii/0165032787900176?via%3Dihub">found that</a> while the drug helped some people with anxiety, it only worked in specific circumstances (such as when anxiety was related to physiological symptoms like a racing heart or hyperventilation) and was ineffective at relieving symptoms of generalized anxiety. Other small studies have assessed propranolol and other beta-blockers for the treatment of generalized anxiety disorder and found no benefits, according to a recent <a href="https://journals.sagepub.com/doi/pdf/10.1177/0269881115612236">literature review</a>.</p>
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<p>And even for performance anxiety, the nuances of an appropriate dose and which beta-blocker may be best need further study, Dr. Schneier notes. </p>
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<p>Cells carry different forms of beta-adrenergic receptors, and different beta-blockers interact with them in distinct ways. Propranolol, for example, only exerts its effects for about four hours, and it can cross the blood-brain barrier to bind to receptors within the nervous system. (The extended release form, which is effective for about 24 hours, is not used because it takes effect more slowly than would be useful for situational anxiety.) Although propranolol is the most commonly used, <a href="https://academic.oup.com/milmed/article-abstract/185/11-12/e1954/5874725">studies</a> suggest other beta-blockers, such as atenolol and metoprolol, might also be effective. </p>
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<p>There have also been no systematic studies comparing one beta blocker to another. “It’s all speculation, really,” says Dr. Schneier. </p>
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<h2 class="wp-block-heading">The Risks, Side Effects, and Trade-offs of Beta Blockers for Anxiety</h2>
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<p>Beta-blockers are prescribed differently for performance anxiety than they are for heart disease, where they are typically taken daily at a consistent dose, says <a href="https://www.linkedin.com/in/melanie-yabs-pharmd-ms-bcpp-37ba0421">Melanie Yabs, PharmD</a>, a clinical pharmacist at the University of Pittsburgh Medical Center Western Psychiatric Hospital. To ease situational anxiety, the meds are usually prescribed at a lower dose (half or less of what’s used for heart conditions), and only taken “as needed” – when a person feels the need for it to cope with a situation. </p>
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<p>Although propranolol and other beta-blockers are generally safe and not habit-forming, they still pose risks. Even among those without pre-existing conditions, propranolol can cause <a href="https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/016418s080,016762s017,017683s008lbl.pdf?ref=linkstock">adverse reactions</a> that range from fatigue and nausea to relatively rare but serious autoimmune conditions and allergies, including anaphylaxis. While interactions with other medications are uncommon when propranolol is used occasionally for performance anxiety, Dr. Schneier notes, they are not impossible.</p>
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<p>At the same time, experts say the overall risk profile remains low when the drugs are used appropriately. </p>
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<p>“Generally speaking, [the use of beta-blockers] is not really hazardous,” says Serge Steenen, M.D., a physician at the Amsterdam University Medical Center in the Netherlands who has studied the use of beta-blockers for <a href="https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2022.842353/full">anxiety before dental surgery</a>. Concerns over the inappropriate use of propranolol in healthy young adults may be “a little bit overstretched,” he says. </p>
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<p>For people with underlying health conditions, however, the risks can be greater. People who have lower-than-average blood pressure may feel dizzy or lightheaded when they take a beta-blocker, and studies suggest beta-blockers <a href="https://www.sciencedirect.com/science/article/abs/pii/S001236921535947X">can worsen symptoms</a> of asthma and certain heart conditions. </p>
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<p>R. Freeman (who asked for privacy regarding her full name), a retired public relations professional, says she used propranolol to cope with debilitating anxiety before work presentations for years. Although the medication helped her thrive at work, it left her feeling so exhausted that she often felt like she might pass out. The pills also hobbled her workouts, she says, which are an essential part of her physical and mental well-being. As a person with chronically low blood pressure, Freeman says she felt too tired to exercise on days she had to take the medication. </p>
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<p>“It helped me survive, but I hated taking it."</p>
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<p>“It helped me survive, but I hated taking it,” she says. “You really shouldn't be working out, lifting weights at the gym, while you still are under the influence of propranolol. So I was constantly at odds with that.”  </p>
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<h3 class="wp-block-heading">Easy to Access, Easy to Misuse</h3>
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<p>Although beta-blockers are not habit-forming when taken as directed, their strong safety profile and relatively mild side effects can make them easy to misuse, including without a doctor’s prescription.</p>
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<p>In two 2025 studies, researchers highlighted the “inappropriate” use of propranolol by <a href="https://link.springer.com/article/10.1186/s12909-025-07094-x">medical students in Palestine and Jordan</a> to help them cope with the stress of clearing their exams. At both universities, students reported “self-prescribing” propranolol. Of the 584 students <a href="https://www.frontiersin.org/journals/medicine/articles/10.3389/fmed.2025.1586068/full">surveyed at the University of Jordan</a>, three-quarters were aware of the risks of taking the drug without supervision, yet 58% used it anyway, with 36% of users reporting experiencing dizziness and fatigue. </p>
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<p>It’s also possible that someone struggling with anxiety may take higher doses on their own in an attempt to control their symptoms, says Dr. Steenen. A <a href="https://pharmaceutical-journal.com/article/feature/the-dangers-of-propranolol-for-anxiety">2025 report</a> in <em>The Pharmaceutical Journal </em>underscores that concern, citing a fatal overdose in a teenager with anxiety and depression.</p>
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<p>These risks may be compounded when the drugs are obtained online. In those cases, says Dr. Schneier, beta-blockers may be prescribed “without a careful evaluation or without any concern about potential side effects.”</p>
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<h2 class="wp-block-heading">Do You Really Need Beta Blockers? Why Some Anxiety Is Actually Good For You</h2>
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<p>Dr. Steenen recalls taking propranolol a couple of times in his life: once before his driving test at the age of 21, and later for an important presentation. On both occasions, he remembers feeling the medication helped, but not to the point of making him feel too relaxed to perform. “I think there’s an optimal kind of stress,” he says. “You need to be slightly stressed — but just slightly.”</p>
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<p>Finding that optimal level is critical, Dr. Schneier says. He warns against the assumption that people should not experience anxiety at all, as it can be a powerful motivator to perform. “It’s not a great goal to try to eliminate people’s anxiety,” he says. “It’s much better to have people learn to accept anxiety — if it’s moderate — and to channel that into their performance.” </p>
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<p>“It’s not a great goal to try to eliminate people’s anxiety. It’s much better to have people learn to accept anxiety — if it’s moderate — and to channel that into their performance.” </p>
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<p>Treatments for performance anxiety should be tailored based on various factors, including a person’s anxiety levels and how frequently a person has to cope with the problem, Dr. Yabs says. </p>
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<p>Dr. Yabs adds that the occasional use of beta-blockers for performance situations, as advised by a doctor, can be good. But not if someone feels anxious every day. That could indicate a serotonin imbalance and it’s important to consider alternatives, she says. </p>
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<p>For people who need support more regularly, cognitive behavioral therapy (CBT) — which has the <a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC8475916/">strongest evidence base</a> supporting its use and benefits — is likely to be the first line of treatment rather than a beta-blocker, adds Dr. Schneier. </p>
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<p>In addition to CBT, public speaking training can also ease feelings of anxiety. Freeman, for example, joined Toastmasters International, a group that helps build public speaking skills and confidence in presentations. When considering solutions, it’s important for individuals to speak with a therapist or physician to understand what may work best for their specific needs and their health, says Dr. Yabs. </p>
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<p>While beta-blockers are one of many valuable approaches doctors can use to treat anxiety, they’re not a quick-fix solution to be treated casually, Dr. Schneier cautions. People should speak with a doctor and consider alternatives depending on their needs. “There’s various kinds of self-help approaches that can be really helpful for performance anxiety,” he says. What concerns him most about beta-blockers, he adds, is that people may use them “without getting a careful evaluation, or considering alternative approaches to treatment.”</p>
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<p>As for Freeman, she says her use of the medication has shifted over time. </p>
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<p>While she says she would take propranolol a few times a week while at work, her anxiety over speaking in public has eased since she retired. “I don't have the same fears that I used to have when I was in the corporate world,” she says. “I think as we go through the stages of our lives, we go from coping with one thing to then coping with something brand new. You just have to figure out what’s going to get you through the next day.”</p>
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