Propranolol and Performance Anxiety in Musicians: History and Context.
For decades, musicians have been fortunate to have propranolol and other beta blockers to manage the physical symptoms of stage fright. These medications can be helpful in certain situations and many musicians turn to medications when auditions become destabilizing. This article provides an evidence-informed overview of how propranolol works, when it may be helpful, and why many musicians benefit from combining medical and psychological approaches to performance anxiety.
Propranolol has an interesting History in Music
For nearly 50 years, propranolol has been quietly used by musicians to manage performance anxiety. Yet despite its widespread use in orchestras, conservatories, and concert halls worldwide, many musicians and teachers don't fully understand what this drug actually does and what it can realistically accomplish, why it works for some people and not others, and what it definitively cannot do.
PART 1: How It All Began
By the 1970s, musicians had discovered propranolol! The story goes that a violinist with the London Symphony Orchestra, facing a career-ending stage fright, tried propranolol on the advice of his cardiologist neighbor. His subsequent performance was so transformed that within months, beta-blockers were spreading through orchestras like a closely guarded secret.
These drugs were invented by Sir James W. Black in 1964. Three years later, in 1967, Propranolol became the first beta blocker to be approved by the Food and Drug Administration (FDA) for specific medical purposes. More than a decade later, in 1979, Thomas and Charles Brantigan published the first medical research in America supporting the effects of beta blockers for relieving stage fright.
The Pivotal 1982 Article
In 1982, Tom Hall of the Chicago Symphony published a significant article titled "A Cure for Stage Fright?" in Senza Sordino, the official publication of the International Conference of Symphony and Opera Musicians (ICSOM). This article introduced beta blockers to a community of musicians who eventually adopted these drugs, but it also discussed the potential dangers and ethical issues of the practice.
Notably, Hall's article—even while introducing propranolol to the music world—included important cautions, asking whether use by performers at auditions gave an unfair edge over competition.
How Widespread Is It Really?
The adoption has been substantial and continues to grow:
A stunning 72 percent of professional musicians have used beta-blockers for performance anxiety according to research presented in the documentary "Composed."
In a 1987 formal study on stage fright with 2,000 professional musicians from the 51 largest orchestras in the United States, more than 27 percent of those musicians used beta blockers for their nerves at least once, if not more often. Of those, 70 percent said that they had not gotten prescriptions for the drugs.
A more contemporary review through cross sectional survey by Kuwabara et al (2024) evaluated 311 musicians (40% full-time ensemble musicians) and found that beta blockers were used for performance enhancement by 32% of musicians, with 57% identifying they take beta-blockers specifically when auditioning for a job.
PART 2: WHAT IS PROPRANOLOL AND HOW DOES IT WORK? The Drug Itself
Propranolol is a beta blocker—a type of medication that works by blocking the beta receptors found in your body. Developed in the 1960s, propranolol is one of the oldest and most widely used beta blockers in existence.
Propranolol appears in the blood after 30 minutes and has a maximum effect between 60 and 90 minutes when taken orally.
How It Affects Your Body
Propranolol works by blocking these receptors. With these receptors blocked, stress hormones like adrenaline don't have their normal effects on your heart and other tissue. This means you're less likely to experience physical symptoms like shaking, sweating or a rapid pulse.
Critically, since propranolol only blocks beta receptors, it doesn't actually stop the psychological effects of anxiety. You might still feel nervous before delivering a speech or meeting someone, but it's less likely to result in any kind of physical reaction. Interestingly, although propranolol doesn't directly affect your brain, it can help to make you feel less nervous. Without the shaking, rapid heartbeat and sweating that usually happens when you feel anxious, it can become easier to relax, perform and stay focused.
The Critical Distinction
This last point is crucial and often misunderstood: Propranolol does not eliminate anxiety. It eliminates the physical manifestations of anxiety.
Beta blockers do not alleviate anxiety or inner nervousness, they just block the outward, physical signs of anxiety. The drugs only block the physiological action of adrenaline, they don't stop it, or solve the underlying causes of the anxiety.
PART 3: WHAT PROPRANOLOL ACTUALLY DOES (AND WHAT IT DOESN'T) What Propranolol Successfully Addresses
Research consistently shows propranolol effectively reduces:
Physical impediments to performance caused by stage fright, and even eliminates the dry mouth so frequently encountered. The quality of musical performance as judged by experienced music critics is significantly improved.
Physical symptoms like tremor, rapid heart rate, and nervousness during performance situations
Physical aspects of anxiety, and significantly relieved other symptoms including shortness of breath, chest pains, and weakness
The Dosage and Timing
For situational performance anxiety, a single dose of propranolol (40 mg) taken approximately one hour before the event has shown effectiveness. Improvement is typically noted within 1-2 hours of administration.
There's no one-size-fits-all dose of propranolol for anxiety. For short-term or situational anxiety, many people take 10 to 40 mg about an hour before the event. Some go up to 80 mg if needed, but always under a doctor's watch.
But wait? Is this the miracle drug we all want?
With all that this remarkable drug can do, it has limitations:
It does not cure anxiety. It's also important to remember that propranolol is not a cure for anxiety and may not be suitable for everyone.
It does not work for everyone. Beta blockers aren't as effective for people whose anxiety doesn't manifest in mainly physiological ways.
It does not address underlying anxiety thinking. Beta blockers will not help a musician play beyond their technical and musical capabilities (if only!), and they're no substitute for careful practice and preparation. They don't increase mental clarity, improve technical accuracy, or enhance creativity. Rather, they relieve symptoms that would otherwise interfere with an individual's ability to play well despite intense stage fright.
It does not produce long-term benefits. Long-term efficacy beyond 4 weeks has not been well- established.
PART 4: WHY IT WORKS FOR SOME MUSICIANS AND NOT OTHERS'
The Type of Anxiety Matters
Propranolol works best when:
Your anxiety manifests primarily as physical symptoms (racing heart, trembling, sweating) You have specific, situational anxiety (before a particular performance)
Your anxiety doesn't stem from deep cognitive patterns or perfectionism
Propranolol works poorly when:
Your anxiety is primarily cognitive (worrying thoughts, catastrophizing, self-doubt) You struggle with perfectionism or impostor syndrome
Your anxiety involves complex emotional patterns
Bringing up propranolol is resurrecting a dead body," said a Boston University psychologist, noting that beta-blockers "aren't as effective for people whose anxiety doesn't manifest in mainly physiological ways."
The Dosage Response
The medication is most effective for relatively mild symptoms like the tremor experienced by anxious performers rather than severe symptoms of panic attacks.
This means if your anxiety is severe, propranolol alone may not be sufficient.
The Tolerance Problem
One significant issue that develops with repeated use:
Although beta blockers are not physically addictive, they have the potential for psychological dependence. Like all drugs, more than occasional use of beta blockers will increase tolerance. Over time, the dosage and/or frequency will need to be increased to produce the same effects.
Some users may feel that they can't go on stage without them.
PART 5: WHAT RECENT RESEARCH ACTUALLY SAYS
An important finding from 2024-2025 research: Although beta-blocker prescriptions have increased across all indications in America, Canada, and the UK, there is no up-to-date evidence available (off-label) for beta- blocker prescriptions for anxiety in America or Canada.
The Latest Systematic Review (2024-2025)
Most recent comprehensive analysis: Beta-blocker prescriptions for patients with anxiety increased substantially between 2003 and 2018, yet there is no clinical guidance concerning their use. A previous review of propranolol concluded there was insufficient evidence to support its use. Additional data have been published, including some evidence for other beta-blockers.
This is significant: despite widespread use, the evidence base for propranolol's effectiveness in anxiety disorders remains limited.
What Works Best for Musicians' Performance
A review of drug interventions for Music Performance Anxiety concluded that 'β-blockade reduces some of the physiological symptoms of performance anxiety' and importantly, that 'the drugs should be used only occasionally and along with psychological therapies.'
This recommendation is that propranolol should be used alongside psychological treatment, not as a stand-alone solution.
PART 6: SIDE EFFECTS
Common side effects include nausea, abdominal pain, and constipation. Fatigue can also be a side effect, but it often gets better over time.
Propranolol is NOT appropriate for musicians with:
Asthma (it may worsen the symptoms of asthma) Diabetes, or thyroid conditions
Serious risks can include lightheadedness all the way up to reports of congestive heart failure and the serious allergic reaction known as anaphylaxis.
Beta blockers are inexpensive and prevalent in competitive music communities, making them all too easy to obtain from friends rather than from a doctor's prescription. In rare cases, beta blockers can cause serious complications, and only a doctor who knows your history can help you decide whether the potential benefits outweigh the risks.
PART 7: THE ETHICAL CONSIDERATIONS
From the beginning, propranolol's use in auditions has raised ethical questions:
Might not the use of potent prescription drugs by a performer at an audition give him an unfair edge over the competition just as it might to the athlete? Does an audition by a candidate who uses Propranolol reveal with greater or lesser accuracy how he will play on the job?
These questions, posed in 1982, remain relevant today.
PART 8: WHAT MUSIC EDUCATORS COULD TELL STUDENTS
If a student asks about propranolol, educators might explain:
What it does: "It reduces physical symptoms of anxiety like trembling and rapid heartbeat."
What it doesn't do: "It doesn't address the thinking patterns behind anxiety, it doesn't cure performance anxiety, and it only works for acute situations and not for building lasting confidence."
The real issue: Most cases of performance anxiety can be resolved by getting to the heart of the problem. Often, a musician simply needs more experience performing to build up confidence and learn to enjoy it. Sometimes stage fright has deeper roots that may improve with the help of a therapist.
PART 9: ALTERNATIVES AND WHEN TO CONSIDER THEM
This recommendation suggests that if a musician is considering propranolol, they might also simultaneously benefit from exploring:
Performance psychology coaching
Cognitive behavioral therapy
Exposure-based training (regular performance opportunities) and Psychological skills development
When Propranolol Makes Sense
So, what might this mean for you? Propranolol is potentially helpful if:
You have a one-time high-stakes performance (audition, major concert)
Your anxiety manifests primarily as physical symptoms.
You have tried other approaches without success.
You've consulted with a physician about your medical history
You're using it occasionally, not as your only anxiety management strategy
Do You Want Additional Support?
For musicians who find that medication reduces symptoms but does not fully resolve performance anxiety, structured psychological treatment can help address the cognitive and emotional mechanisms underlying performance pressure.
Breakthrough Performance Center integrates Acceptance and Commitment Therapy (ACT) and Inference-Based Cognitive Behavioral Therapy (I-CBT) in a framework designed specifically for performers.