What are the treatment options for essential tremor (ET)?

From the Guidelines

Essential tremor can be effectively treated with propranolol, a beta-blocker that has been used for over 40 years, with other beta-blockers like metoprolol also being effective depending on the case. When considering treatment options for essential tremor, it's crucial to prioritize medications that have a proven track record of efficacy and safety. According to a recent study published in 2022 1, propranolol has been a mainstay in the treatment of essential tremor, and its effectiveness is well-documented. Some key points to consider when treating essential tremor include:

• The use of beta-blockers, such as propranolol, as a first-line treatment option
• The potential effectiveness of other beta-blockers, like metoprolol, in certain cases
• The importance of individualizing treatment based on the patient's specific needs and medical comorbidities
• The need to consider lifestyle modifications, such as avoiding caffeine and other stimulants, to help manage symptoms
• The potential benefits of physical therapy and other non-pharmacological interventions in improving daily functioning. In terms of specific treatment regimens, propranolol can be started at a low dose and gradually increased as needed, with the goal of reducing tremor amplitude by 50-60% in most patients. It's also important to note that while other medications, such as primidone, topiramate, and gabapentin, may be effective in treating essential tremor, propranolol remains a widely used and well-established treatment option, as supported by the 2022 study 1.

From the Research

Essential Tremor Treatment Options

• Pharmacological treatments:
  • Propranolol and primidone are classified as clinically useful for limb tremor 2, 3, 4, 5
  • Topiramate is possibly useful for doses higher than 200 mg/day 2, 3, 6
  • Alprazolam and botulinum toxin type A are possibly useful for limb tremor 2, 3, 4, 6
• Surgical interventions:
  • Unilateral Ventralis intermedius thalamic DBS, radiofrequency thalamotomy, and MRI-guided focused ultrasound thalamotomy are considered possibly useful for limb tremor 2, 3, 4, 5
  • Deep brain stimulation (DBS) in the thalamic nucleus ventrointermedius or neighbouring subthalamic structures reduces tremor by about 90% 5

Treatment Efficacy and Safety

• Propranolol, primidone, and topiramate (>200 mg/day) have robust evidence supporting their efficacy for limb tremor 2
• Botulinum toxin A may reduce hand tremor but is associated with dose-dependent hand weakness 3, 4, 6
• Surgical interventions carry a small risk of major complications, but some adverse events may resolve with time or with adjustment of stimulator settings 3, 5

Future Treatment Directions

• Alternative therapeutic options, such as T calcium channel blockers, modulators of GABAA receptors, GABAB receptors, and glutamatergic neurotransmission, and drugs that decrease the expression of LINGO-1, may be interesting options for the future 6