Propranolol for Anxiety: Dosage, Timing, and What It Actually Feels Like

Your heart races before presentations. Your hands shake during interviews. You've tried deep breathing and positive thinking—but your body doesn't listen. You're not anxious in your mind; your body is anxious for you.

Here's what propranolol does differently: it blocks the physical symptoms of anxiety at the source.

You swallow the pill sixty minutes before your big moment. Your heart rate steadies. Your hands calm. But here's the critical distinction most providers skip: you might still feel mentally anxious—because propranolol only addresses the physical symptoms, not the cognitive ones.

This disconnect is exactly why understanding propranolol matters. Research shows it works brilliantly for performance anxiety where the body betrays you (Steenen et al., 2016). But for chronic worry and racing thoughts? That requires a different approach entirely.

What Is Propranolol?

Propranolol is a beta-blocker—a medication originally designed for heart conditions like high blood pressure and irregular heartbeat. It blocks beta-adrenergic receptors, which are the targets for adrenaline and noradrenaline (your body's stress hormones).

Think of it as turning down the volume on your body's physical stress response.

What propranolol does:

• Slows heart rate
• Reduces palpitations
• Decreases hand tremor
• Lowers blood pressure
• Reduces sweating

What propranolol does NOT do:

• Stop racing thoughts
• Reduce worry or rumination
• Eliminate fear of judgment
• Address the root cause of anxiety

This is critical: propranolol treats the physical manifestations of anxiety, not the anxiety itself.

How Propranolol Works for Anxiety (The Feedback Loop)

Anxiety creates a vicious cycle:

1. Your brain perceives a threat (real or imagined)

2. Your body releases adrenaline

3. Your heart races, hands shake, you sweat

4. Your brain notices these physical symptoms

5. Your brain interprets them as confirmation of danger

6. More adrenaline is released

7. The cycle intensifies

Propranolol interrupts this cycle at step 3. By blocking the physical symptoms, it prevents the feedback loop from spiraling.

When this works brilliantly:

Your anxiety is situational and primarily physical. You're a musician facing an audition. A public speaker before a presentation. You know what you're doing—your mind is clear—but your body is betraying you with tremor and rapid heartbeat.

Propranolol breaks the cycle. Your body stays calm. Without physical symptoms to amplify the fear, you perform well.

When this doesn't work:

Your anxiety is cognitive. You're catastrophizing. Ruminating about what could go wrong. Fearing judgment. Even with a steady heart rate and calm hands, your mind is racing.

This is why propranolol has strong evidence for performance anxiety but insufficient evidence for generalized anxiety disorder or panic disorder.

A Real Example:

David, 29, was a software engineer who dreaded team presentations. His skills were excellent, but visible trembling and voice quavering made him avoid leadership opportunities. Propranolol 20mg taken 60 minutes before presentations eliminated the physical symptoms. "My brain finally caught up with my body," he said. "I actually enjoy presenting now."

Before We Talk Dosage: What We Should Investigate First

After 19 years in the ICU, I learned that symptoms are signals. When someone has palpitations, tremor, and anxiety, we don't just treat the symptoms—we investigate why they're happening.

Medical causes of anxiety symptoms that propranolol will mask but not treat:

Hyperthyroidism

10-40% of patients with hyperthyroidism present with anxiety as their primary symptom. Your thyroid is overproducing hormones, revving your metabolism, racing your heart, and making you feel wired.

What to check:

• TSH (thyroid-stimulating hormone)
• Free T4
• Free T3

Why it matters: Propranolol will slow your heart rate, but your thyroid storm continues. You need thyroid treatment, not beta-blockers.

Iron Deficiency

Even with "normal" hemoglobin, low ferritin (iron stores) causes:

• Palpitations
• Exercise intolerance
• Restless sensations
• Difficulty concentrating

Patients describe it as "anxious energy" or "feeling wired but exhausted."

What to check:

• Ferritin (target >50 ng/mL, optimal >75)
• Complete iron panel

Why it matters: Your heart is racing because it's trying to compensate for poor oxygen delivery. Propranolol slows the heart without fixing the underlying oxygen problem.

Vitamin D Deficiency

Research shows vitamin D deficiency is associated with a 2.4-fold increased risk of anxiety symptoms. Levels below 30 ng/mL consistently correlate with increased anxiety and mood disturbances.

What to check:

• 25-OH Vitamin D (target 40-60 ng/mL)

Magnesium Deficiency

Magnesium regulates the nervous system. When it's low, you get:

• Muscle tension
• Heart palpitations
• Restlessness
• Difficulty relaxing

What to check:

• Serum magnesium (though this is often normal even when cellular magnesium is depleted)
• RBC magnesium (more accurate but less commonly ordered)

Blood Sugar Dysregulation

Reactive hypoglycemia—blood sugar crashes after meals—creates identical symptoms to panic attacks:

• Racing heart
• Sweating
• Tremor
• Intense anxiety

What to check:

• Fasting glucose
• HbA1c
• Consider continuous glucose monitor if symptoms correlate with meals

The Point: At Horizon Peak Health, we investigate these factors before prescribing propranolol. If your anxiety is driven by thyroid dysfunction or iron deficiency, beta-blockers mask the problem without solving it.

Propranolol Dosage for Anxiety: The Practical Protocols

All use of propranolol for anxiety is off-label. The FDA has approved it for high blood pressure, irregular heartbeat, migraine prevention, and essential tremor—but not anxiety.

That said, it's widely prescribed and has decades of clinical use data.

Performance Anxiety (Situational)

Typical dosing:

• 10-20mg: Minimal symptoms, mild presentations, first-time trial
• 20-40mg: Moderate symptoms, typical effective range
• 40-80mg: Severe symptoms, experienced users

Timing:

• Take 60-90 minutes before the event
• Onset: 30-60 minutes
• Peak effect: 1-4 hours
• Duration: 4-6 hours

Example protocol:

• Job interview at 2:00 PM → Take 20-40mg at 12:30 PM
• Wedding speech at 7:00 PM → Take 20-40mg at 5:30 PM

Starting conservative:

If you've never taken propranolol, start with 10mg. See how your body responds. Some people are highly sensitive; others need 40mg for effect.

Important: Don't take it for the first time right before your big event. Test it on a low-stakes day to see how you feel.

Social Anxiety (Performance Subtype)

Some people with social anxiety have a "performance subtype"—they're fine in small groups but panic in presentations, meetings, or situations where they're the focus.

Dosing:

• 10-40mg PRN (as needed) before situations that trigger physical symptoms
• NOT effective for generalized social inhibition (fear of judgment in all social situations)

Evidence: Mixed. A 2016 meta-analysis found insufficient evidence for propranolol in social anxiety disorder overall, but clinical experience suggests benefit for the performance subtype.

When Physical Symptoms Aren't the Main Problem

For chronic, diffuse worry (GAD):

If your primary symptoms are racing thoughts, rumination, and constant worry rather than physical symptoms like racing heart and tremor, propranolol addresses only part of the picture. For these presentations, we investigate what's driving the cognitive symptoms—often thyroid dysfunction, blood sugar dysregulation, sleep disorders, or inflammation—while considering other treatment approaches.

For panic attacks:

Panic involves catastrophic cognitive interpretations that propranolol doesn't address. Physical calm doesn't stop the thought spiral. Our approach: investigate what's triggering panic (medical factors are common), address those factors, and consider cognitive-behavioral strategies alongside any medication.

If you're taking propranolol daily and it helps:

That's useful information. It tells us there's a physical component worth investigating. Why is your body producing these symptoms? Thyroid? Iron? Sleep apnea? The fact that propranolol helps doesn't mean we should stop there—it means we should dig deeper into what your body is telling us.

What Propranolol Actually Feels Like

First 30 minutes:

Most people feel nothing. Some report mild lightheadedness or slight fatigue.

60-90 minutes (peak effect):

• Heart rate noticeably slower (you can feel it if you check your pulse)
• Absence of palpitations
• Hands steady (if they were tremoring before)
• No sweating even in situations that normally trigger it

Mental state:

• Thoughts remain unchanged
• Worries persist
• Fear of judgment unchanged
• Cognitive processing unchanged

Physical sensation:

"I feel calm in my body but still anxious in my mind."

This is the propranolol paradox. For performance anxiety, it's perfect—you don't need your mind to be different, you just need your body to cooperate. For generalized anxiety, it's frustrating—your body is calm, but your thoughts are still racing.

Propranolol vs. Other Anxiety Treatments

Propranolol vs. Xanax (Benzodiazepines)

• Targets: Physical symptoms only — Both physical and mental anxiety
• Sedation: None — Yes (often significant)
• Cognitive impairment: None — Yes (memory, reaction time)
• Addiction risk: None — High (physical dependence develops quickly)
• Withdrawal: Only if used daily for weeks — Severe, potentially dangerous
• Safe long-term: Yes — No (tolerance, dependence, cognitive decline)
• Effect onset: 30-60 minutes — 15-30 minutes
• Best for: Situational performance anxiety — Acute panic, short-term crisis

The trade-off: Propranolol won't reduce mental anxiety, but it also won't impair you or create dependence.

Propranolol vs. SSRIs (Lexapro, Zoloft)

• Targets: Physical symptoms — Underlying anxiety disorder
• Use: As-needed (PRN) — Daily, long-term
• Time to effect: 60 minutes — 4-6 weeks
• Side effects: Fatigue, cold hands, bradycardia — Sexual dysfunction, GI upset, initial anxiety increase
• Best for: Situational anxiety — Chronic anxiety disorders

When to use which:

• Propranolol: You have occasional high-stress situations and otherwise function well
• SSRIs: You have persistent anxiety that interferes with daily life

Propranolol vs. Therapy (CBT)

Propranolol treats symptoms. Therapy addresses the underlying cognitive patterns that generate anxiety.

Best outcome: Both. Use propranolol for immediate symptom control while you build cognitive skills through therapy to address the root thought patterns.

Safety and Side Effects

Common Side Effects

• Fatigue (most common)
• Cold hands and feet (reduced circulation to extremities)
• Dizziness (from blood pressure lowering)
• Vivid dreams or nightmares
• Bradycardia (slow heart rate, <60 bpm)

Serious Contraindications (DO NOT TAKE IF)

Asthma or COPD:

Propranolol can cause life-threatening bronchospasm. This is an absolute contraindication.

Heart block or severe bradycardia:

If your resting heart rate is already below 60 bpm or you have conduction abnormalities, propranolol can worsen these.

Severe heart failure:

Beta-blockers can worsen heart failure in some patients.

Important Warnings

If you have diabetes:

Propranolol masks hypoglycemia symptoms (shakiness, rapid heartbeat). You might not realize your blood sugar is dangerously low.

If you take it daily:

Don't stop abruptly. Sudden withdrawal can cause rebound high blood pressure and increased heart rate. Taper gradually over 1-2 weeks.

Pregnancy:

Generally considered relatively safe, but discuss with your OB/GYN. Propranolol crosses the placenta.

Drug Interactions

Check with your provider if you take:

• Other blood pressure medications (can cause dangerous drops)
• Calcium channel blockers
• Antiarrhythmics
• Insulin or diabetes medications

Real Patient Questions (From Reddit, Answered by a Provider)

"Will propranolol cause hair loss?"

Rare, but reported. If you notice increased shedding, it's worth discussing with your provider. Usually reversible when stopped.

"Can I drink coffee with propranolol?"

Yes, but caffeine increases heart rate and anxiety while propranolol decreases it. They work against each other. You might need to reduce caffeine intake.

"Can I drink alcohol with propranolol?"

Both lower blood pressure. Combined, they can cause dizziness or fainting. If you drink, do so cautiously and stay hydrated.

"How low will my heart rate go?"

Typically 10-20 bpm reduction. If your resting heart rate is 75 bpm, expect 55-65 bpm on propranolol. If it drops below 50 bpm or you feel faint, contact your provider.

"Does propranolol help with the physical symptoms of ADHD stimulants?"

Some people use it off-label to reduce stimulant-induced jitteriness and rapid heartbeat. Discuss with your prescriber—don't add it on your own.

"Can I take propranolol every day?"

You can, but it's not typically effective for daily anxiety. If you're taking it daily and feeling better, investigate why—you might have an underlying medical condition (thyroid, etc.) that's being masked rather than treated.

How to Get Help: The Diagnostic Approach

If you're considering propranolol for anxiety, the question isn't just "What dose should I take?" It's "Why am I anxious?"

At Horizon Peak Health, we approach anxiety systematically:

Step 1: Comprehensive Assessment (75-90 minutes)

• Full medical and psychiatric history
• Systematic review of all body systems
• Identify patterns: Is this situational? Chronic? Physical? Cognitive?

Step 2: Lab Investigation

• TSH, Free T4, Free T3 (thyroid)
• Ferritin and complete iron panel
• Vitamin D, B12, magnesium
• Fasting glucose, HbA1c
• Complete metabolic panel

Step 3: Identify Contributing Factors

• Medical causes (thyroid, iron, vitamin D, blood sugar)
• Medication side effects (stimulants, steroids, etc.)
• Substance use (caffeine, nicotine, alcohol)
• Sleep disorders (sleep apnea causing daytime anxiety)

Step 4: Targeted Treatment

• Optimize medical factors first
• If anxiety persists, appropriate psychiatric treatment
• Propranolol PRN if performance anxiety is the primary issue
• SSRIs or therapy if chronic anxiety disorder

Step 5: Monitor and Adjust

• Monthly follow-ups initially
• Recheck labs after treatment
• Adjust medications based on response
• Transition to maintenance once stable

The Bottom Line

Propranolol is an excellent tool for situational performance anxiety where physical symptoms (rapid heartbeat, tremor, sweating) are the primary problem.

It's not effective for chronic worry, rumination, or generalized anxiety—because those are cognitive, not physical.

And most importantly: propranolol treats symptoms, not causes.

If you have palpitations and anxiety, we should ask why before we suppress the symptoms. Is it your thyroid? Your iron? Your blood sugar? Sleep apnea? A medication side effect?

Propranolol might get you through your wedding speech. But if you're using it daily just to function, we're missing something.

After 19 years in the ICU, I learned that the body always tells a story. Physical symptoms are the plot points. Medications like propranolol can edit the story, but they don't change what's being told.

At Horizon Peak Health, we read the whole story before we start editing.

---

Ready for a Comprehensive Evaluation?

If you're dealing with anxiety symptoms—whether physical, mental, or both—we take the time to investigate thoroughly.

What to expect:

• 75-90 minute comprehensive assessment
• Complete lab workup to identify medical factors
• Systematic investigation of all contributing causes
• Evidence-based treatment plan addressing root causes, not just symptoms

Investment: Initial evaluation and follow-ups covered by most insurance plans (cash rates: $350-450 initial, $150-200 follow-ups; sliding scale available for uninsured). Propranolol is inexpensive ($4-15/month generic).

Locations: Anxiety treatment in Rancho Palos Verdes, Anxiety treatment in Phoenix, Anxiety treatment in Chandler, and telehealth throughout California and Arizona

Book Your Consultation →

Most patients start feeling significantly better within 2-3 months once we identify and treat all the factors driving their symptoms—not just the most obvious ones.

---

Disclaimer: This article is for educational purposes only and does not constitute medical advice. Propranolol is a prescription medication that should only be used under the supervision of a qualified healthcare provider. All medical decisions should be made in consultation with your physician. If you are experiencing severe anxiety, suicidal thoughts, or a mental health emergency, call 988 (Suicide & Crisis Lifeline) or go to your nearest emergency room.

---

References

• Brantigan, C.O., et al. (1982). Effect of beta blockade and beta stimulation on stage fright. American Journal of Medicine, 72(1), 88-94.
• Steenen, S.A., et al. (2016). Propranolol for the treatment of anxiety disorders: Systematic review and meta-analysis. Journal of Psychopharmacology, 30(2), 128-139.
• Meibach, R.C., et al. (1987). Comparative efficacy of propranolol, chlordiazepoxide, and placebo in the treatment of anxiety: A double-blind trial. Journal of Clinical Psychiatry, 48(9), 355-358.
• Ravaris, C.L., et al. (1987). A controlled study of alprazolam and propranolol in panic-disordered and agoraphobic outpatients. Journal of Clinical Psychopharmacology, 7(5), 297-303.