From the Guidelines
Propranolol is the recommended first-line pharmacological treatment for essential tremor, with a dosage of 40-320 mg daily in divided doses, due to its efficacy in reducing tremor amplitude in 40-70% of patients, as supported by the most recent evidence 1. The treatment of essential tremor involves the use of beta-blockers, with propranolol being the most commonly used, as it has been used for more than 40 years to treat this condition. Other beta-blockers, such as metoprolol, may also be effective depending on the case.
- The dosage of propranolol should be started at a low dose (10-20 mg twice daily) and gradually increased to minimize side effects like fatigue, bradycardia, and hypotension.
- For patients who don't respond adequately to first-line agents, alternatives include topiramate (25-400 mg daily), gabapentin (300-3600 mg daily), or benzodiazepines like clonazepam (0.5-6 mg daily).
- Combination therapy may be necessary for refractory cases, and treatment should be individualized based on tremor severity, functional impairment, comorbidities, and potential drug interactions.
- Patients should be monitored for efficacy and side effects, with dose adjustments as needed, and for severe, medication-resistant tremor, referral for consideration of deep brain stimulation or focused ultrasound may be appropriate, as indicated by the most recent and highest quality study 1.
From the Research
Pharmacological Treatment Options
- First-line pharmacological treatments for essential tremor include propranolol, primidone, and topiramate 2, 3, 4, 5, 6
- Botulinum toxin injections may be useful for patients with refractory essential tremor, especially those with head tremor 3, 4, 5
- Other drugs such as alprazolam and phenobarbital may be considered as alternative options 3, 4
- 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 future treatment 3
Efficacy of Pharmacological Treatments
- Propranolol and primidone are classified as clinically useful for treating essential tremor 4
- Topiramate is also classified as clinically useful, but only for doses higher than 200 mg/day 4
- Alprazolam and botulinum toxin type A are classified as possibly useful 4
Treatment Approach
- The treatment approach for essential tremor should be individualized, taking into account the severity of the tremor, the patient's preferences, and the potential side effects of the treatments 2, 5, 6
- A shared decision-making approach with the patient is necessary to customize the management of essential tremor 2