Can you take propranolol as needed?

In this article:

• Propranolol on-demand
• Understanding propranolol
• Scheduled vs. as-needed use
• Conditions compatible with “as-needed”
• Tips for use
• Safety
• The bottom line

In this article

• Propranolol on-demand
• Understanding propranolol
• Scheduled vs. as-needed use
• Conditions compatible with “as-needed”
• Tips for use
• Safety
• The bottom line

Propranolol, sold under brand names such as Inderal and Hemangeol, is a medication that relaxes blood vessels to improve blood flow and reduce the heart’s workload. It is FDA approved for treating high blood pressure (hypertension) and heart conditions, including arrhythmia, heart attack, and angina pectoris (marked by chest pain).

Because propranolol affects several parts of the body, it impacts the brain and the rest of the nervous system. This allows it to help with more than just cardiovascular problems. It is also used to treat migraines, anxiety, and tremors. For some of these conditions, a healthcare provider may recommend taking propranolol only when symptoms appear, rather than daily. Here’s what to know.

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Can propranolol be your on-demand ally?

Typically, when used to treat heart problems, propranolol is taken as a maintenance medication, once or twice a day, as directed by your primary care provider or cardiologist.

“However, propranolol has also been shown to be effective in managing certain kinds of anxiety, such as social anxiety and performance anxiety,” says Omotola Ajibade, MD, a psychiatrist in Atlanta, Georgia. “In those instances where it is very situationally specific, propranolol is sometimes prescribed on an as-needed basis.”

Understanding propranolol

Propranolol is a beta blocker, a type of medicine that helps calm the body’s response to stress hormones. It works by blocking a receptor that normally responds to chemicals like adrenaline and noradrenaline. These receptors are located throughout the body and help regulate functions such as heart rate, breathing, and muscle contractions. By blocking these signals, propranolol reduces the physical effects that stress hormones can cause.

Your body typically produces adrenaline and noradrenaline in the adrenal gland when you are in a scary or stressful situation. The release of these hormones triggers the body’s fight-or-flight response, a survival mechanism that prepares you to either fight or flee from perceived danger. Effects include:

• Increase in heart rate
• Tensed and trembling muscles
• Increase in blood pressure
• Rapid breathing
• Increase in blood sugar, causing an energy surge

When a beta blocker prevents your body from having this response, your heart beats more slowly with less force and lower blood pressure. A side effect is that you feel calmer and have reduced symptoms of conditions like anxiety disorders.

Notably, propranolol is not a cure for anxiety; it just reduces certain symptoms. “It turns down the volume of adrenaline’s effects but does not stop the signal at its source,” says Eugene Lipov, MD, chief medical officer at Stella Mental Health. 

Scheduled vs. as-needed use

Scheduled use of propranolol involves taking propranolol regularly, usually multiple times daily, to manage a chronic medical condition such as hypertension. 

As-needed use of propranolol is typically only recommended for situational symptoms like performance anxiety. For instance, if you tend to experience anxiety in certain situations like public speaking, your healthcare provider may suggest you take propranolol beforehand to manage anxiety symptoms, such as tension, sweating, tachycardia, and flushing. 

Conditions where “as-needed” propranolol shines

In some situations, propranolol may be taken only when symptoms are expected or begin to appear, rather than on a daily schedule. According to Dr. Lipov, as-needed propranolol is sometimes used to temporarily blunt spikes in the body’s stress response, help people function while waiting for longer-term treatment, and reduce fear associated with predictable triggers, such as flying or public speaking. It works particularly well for the following conditions:

Performance anxiety

Performance, or situational, anxiety is a form of social anxiety that occurs in anticipation of a performance. This may include activities such as public speaking, dancing, or singing. Symptoms include episodes of panic, profuse sweating, tremors, headache, and increased heart rate.

These symptoms are triggered by overactivation of the sympathetic nervous system, also known as the fight-or-flight response. Studies have found that propranolol can help reduce the physical symptoms associated with performance anxiety, making it easier for some people to perform.

PTSD symptoms

Research on propranolol as a long-term treatment for post-traumatic stress disorder (PTSD) is mixed. However, some evidence suggests it may be helpful when taken before trauma memory reactivation.

Trauma memory reactivation is used in certain therapies to reduce the emotional intensity of difficult experiences. The goal is to help reconsolidate the memory with less fear. Taking propranolol beforehand may help reduce physical stress responses, alleviate symptom severity, and enhance cognitive performance in some people.

While research is still developing, early findings suggest propranolol may help reduce PTSD-related symptoms when used in specific therapeutic settings.

Panic attacks

Propranolol may help reduce the physical symptoms that contribute to panic attacks by blocking the effects of adrenaline. This can slow the heart rate and lower blood pressure, which may reduce sensations such as pounding heart, shaking, and shortness of breath that can worsen panic.

Key considerations for “as-needed” use

If your healthcare team determines that as-needed propranolol is right for you, there are some important things to keep in mind:

• Timing: It is recommended to take propranolol approximately one hour before the time you need it to manage your symptoms. For example, an hour before your stage performance. 
• Dosage: A typical dosage for such a situation is between 10 and 40 mg, with a maximum of 80 mg per day. 
• Frequency of use: If you need propranolol frequently, “it is a sign the sympathetic system is chronically dysregulated—not a failure of coping,” says Dr. Lipov. In other words, you may need a different medication to more consistently manage anxiety symptoms.
• Contraindications: Propranolol may not be suitable for people with certain conditions, such as asthma, low blood pressure, slow heart rate, or specific heart rhythm disorders.
• Interactions: Propranolol can interact with other medications, including some antidepressants, blood pressure drugs, and migraine treatments. Alcohol may increase the side effects of propranolol, such as lightheadedness or low blood sugar.

If you have received a diagnosis for GAD, your healthcare provider may prescribe first-line anti-anxiety medications such as SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors), along with psychotherapy. 

Responsible “as-needed” use

To avoid health risks and serious side effects, be sure to take propranolol only as directed by your healthcare team, without exceeding the recommended dose or frequency. It’s designed to provide short-term relief of symptoms, best used alongside long-term treatment for anxiety or panic disorders. Check in with your provider regularly to review side effects, effectiveness, and determine if it’s still working well for you. Never take propranolol while taking another medication without getting medical advice from a healthcare professional first.

The bottom line

Taking propranolol as-needed may work well for you if you experience short-term situational symptoms like performance anxiety. However, it depends on certain factors, including your health status, medical history, and other medications you are taking. 

Before using propranolol, it is essential to discuss safety precautions with your doctor, including whether it is safe to operate heavy machinery or engage in strenuous physical activity. “With any medication that can affect your cardiovascular system, I always recommend staying hydrated and getting up slowly when moving from a seated to a standing position, and vice versa,” Dr. Ajibade points out. “This will minimize the risk of orthostatic episodes, which can cause dizziness and vertigo.”