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Propranolol for tremors: Efficacy, side effects, cost, and more

Propranolol can reduce symptoms of essential tremor by up to 50%
Leandra Beabout
By | Nov. 19, 2024 Medically reviewed by Leslie Greenberg, MD
A wrist being held by another hand: Propranolol for tremors

Key takeaways

  • Propranolol is a beta blocker that is FDA approved for the treatment of essential tremor.

  • Propranolol works by suppressing the central nervous system’s release of “fight or flight” hormones.

  • Propranolol has been shown to reduce tremors by up to 50%.

  • Propranolol’s effectiveness for essential tremor varies depending on the underlying cause and severity of tremors.

  • The cost of propranolol varies depending on an individual’s insurance, dosage, and location, but it is often covered by insurance.

In this article:

Propranolol is a generic beta blocker sold under the brand names Inderal, InnoPran, and Hemangeol. Beta blockers are most often used to treat high blood pressure, but propranolol is also approved by the Food and Drug Administration (FDA) to treat essential tremor (ET). 

“Essential tremor is a neurological condition characterized by involuntary and rhythmic shaking,” explains Raj Singh MD, a primary care physician at HEALOR in Las Vegas. He says that while this movement disorder usually affects the hands, it can also cause head tremors, voice tremors, or shaking of other muscles or upper limbs. Like Parkinson’s disease, essential tremor is progressive. Unlike Parkinson’s, essential tremor does not cause other types of dysfunction.

Because of its effectiveness in the treatment of ET, propranolol is sometimes prescribed off-label to treat shakiness from performance anxiety or panic attacks. Here’s what you need to know about propranolol for treating ET, including the typical dosage and what to expect when taking it.

Propranolol for tremors: How it works

Propranolol is one of two available pharmacologic treatment options for ET. The other is primidone, an anti-seizure drug. Both drugs are effective at reducing tremors by about 50% in most patients, but propranolol is the first treatment healthcare providers consider because it is the only one that’s FDA approved for ET. In some cases, a neurologist might prescribe both of these drugs to be taken together. In other cases, topiramate, or metoprolol, might be prescribed along with or instead of propranolol or primidone. 

So, how does propranolol work for tremors? Dr. Singh explains that propranolol helps “block the effects of epinephrine and norepinephrine,” two stress hormones. By doing so, propranolol helps reduce nervous system activity and the appearance of physical shaking. 

Factors affecting propranolol’s effectiveness for essential tremor

Because propranolol blocks the body’s “fight or flight” response and calms nervous system activity, Dr. Singh says propranolol is most useful for patients whose tremors are “induced by stress or anxiety.” 

Propranolol’s effectiveness also varies depending on the tremors’ characteristics. In general, tremors are defined by two measurements: amplitude and frequency. 

  • Tremor amplitude describes the range of displacement. For instance, a very slight, barely perceptible hand tremor might be described as “fine” or “low” amplitude. In contrast, forceful shaking that causes the hand to move up and down by a full centimeter might be described as “rough” or “high” amplitude. 
  • Tremor frequency describes the speed of displacement. Essential tremor causes a rhythmic shakiness, but the movement speed varies from person to person.

A review of clinical trials published in U.S. Pharmacist found that propranolol works best for high-amplitude, low-frequency essential tremor. In other words, it offers the most tremor suppression for individuals experiencing forceful, low-speed tremors. Still, the review concluded by stating that the effectiveness of propranolol varies from person to person. 

How to use propranolol for tremors

Essential tremor does not always require treatment because tremors are not always severe enough to affect quality of life. For instance, someone with a limb tremor who can still easily carry on daily activities (like writing, drinking from a glass, and using utensils) might choose not to pursue medical treatment. Once an individual is prescribed propranolol for tremors, it can be taken consistently or on an as-needed basis. 

Propranolol dosage varies based on a variety of factors, including symptom severity, age, body size, responsiveness to the drug, and concurrent medications, according to Sue Ojageer, Pharm.D., founder of Pharmacy Mentors and a SingleCare Best of the Best Pharmacy Awards winner.

Consistent usage

Propranolol for essential tremor is usually taken by mouth two to three times daily. In general, adults with essential tremor can expect to start with a dosage of 40 milligrams (mg) twice per day. “Depending on the individual’s response to treatment and side effects, this can be increased, with many patients stabilizing at a daily dose of 120–240 mg, usually divided into two to three doses throughout the day,” Dr. Ojageer explains. “Ultimately, the goal is to start with the lowest effective dose and titrate slowly, balancing symptom control with any potential side effects.” Consistent use of medication helps decrease chronic symptoms in most patients. 

The maximum dose for essential tremor is 320 mg of propranolol per day. As is the case with most medications, a higher dose increases the risk of side effects such as lightheadedness, fatigue, nausea, and gastrointestinal distress. 

Dosage can also vary depending on the form of propranolol. Dr. Ojageer says extended-release formulations (propranolol ER) are taken just once daily. Propranolol ER is available in 60 mg, 80 mg, 120 mg, and 160 mg capsules. The standard dose of propranolol ER is 80 mg.

As-needed usage

Some individuals only take propranolol as needed. When taken to improve job performance or to reduce performance anxiety, propranolol is usually taken 30–60 minutes before the anticipated need for tremor suppression. In that case, dosage may vary. It’s important to stick to the dose or dose range prescribed by your healthcare provider. 

How fast does propranolol work for tremors?

How fast propranolol works for tremors depends on whether an individual takes immediate-release propranolol or long-acting propranolol.

Regular propranolol is an immediate-release medication that usually starts to work within one hour of ingestion. It is fast-acting but must be taken multiple times daily for all-day effectiveness. Standard propranolol has a four-hour half-life. That means about half an individual’s dose remains in the body after four hours. Given that, propranolol is most effective within one to four hours after ingestion. Once four hours have passed, the effects begin to wane.

Propranolol extended-release (ER) is a once-daily medication slowly released into the body and intended to last all day. It has a half-life of about 10 hours, so it has a more gradual onset with effects lasting up to 24 hours.

Propranolol side effects & warnings

Common side effects of propranolol include dizziness, drowsiness, and gastrointestinal issues. In rarer cases, individuals on propranolol experience serious adverse effects such as hallucinations or mood changes. Adverse events are much less common on a low dose.

Who should not take propranolol for tremors?

Propranolol isn’t right for everyone. It is contraindicated (not recommended for use) in certain populations. 

 According to the FDA-approved label, people with the following health conditions should not take propranolol:

  • Cardiogenic shock
  • Sinus bradycardia
  • Greater than first-degree heart block
  • Bronchial asthma
  • Hypersensitivity to propranolol hydrochloride 

In general, propranolol may not be appropriate for patients with impaired liver or kidney function. As is the case with many medications, people who are pregnant, planning to become pregnant, or breastfeeding should talk to their healthcare provider before taking propranolol.

How much does propranolol cost?

“Propranolol is generally covered by most insurance plans for the treatment of essential tremor,” Dr. Ojageer says. “Coverage may vary depending on the specific health insurance plan, as some insurers may require a trial of a generic formulation before approving coverage for brand-name versions or extended-release formulations.” Your copay may also vary based on your dosage, chosen pharmacy, and geographic region.

Individuals without insurance might need to pay out of pocket for this medication. The current retail price of propranolol is $46 for 60, 20 mg tablets. However, a SingleCare prescription discount card can lower the out-of-pocket cost to about $6 for 60, 20 mg tablets.

Bottom line

Propranolol is a beta blocker that is FDA approved for the treatment of essential tremor. On average, propranolol use reduces tremors by about 50%. 

The effectiveness of propranolol for essential tremor depends on the underlying cause of the tremors, as well as the amplitude and frequency of shaking. Individuals with essential tremor need to know that it may take time to find the best dosage, as each person responds to propranolol differently. It’s also important to manage expectations because propranolol is not a cure for tremors—it simply reduces symptoms of essential tremor in many cases.