From the Guidelines
Essential tremor should be treated with propranolol, as it has been effectively used for over 40 years to reduce tremor amplitude in patients. This treatment approach is supported by a study published in 2022 in the journal Hypertension, which mentions the use of propranolol for essential tremor 1. Other beta-blockers, such as metoprolol, may also be effective depending on the individual case.
When considering treatment options, it's essential to note that:
- Propranolol has been a longstanding treatment for essential tremor, with a dosage range of 40-320 mg daily
- Other medications like primidone, topiramate, gabapentin, or benzodiazepines may be considered for patients who do not respond adequately to propranolol
- Lifestyle modifications, such as avoiding caffeine and other stimulants, using weighted utensils, and employing two-handed techniques for drinking, can help manage symptoms
The exact cause of essential tremor remains unclear, but it is often familial, with about 50% of cases showing genetic links 1. While essential tremor is not life-threatening, it can significantly impact quality of life through difficulties with eating, writing, and other daily activities. Therefore, effective treatment with propranolol or other medications, combined with lifestyle modifications, is crucial to improve the patient's quality of life.
From the Research
Definition and Prevalence of Essential Tremor
- Essential tremor is one of the most prevalent movement disorders, characterized by kinetic and postural tremor 2, 3.
- It is the most common cause of tremor involving upper limbs, head, and voice 4.
Pharmacological Treatments
- Propranolol and primidone are classified as clinically useful for treating essential tremor, with propranolol and primidone reducing limb tremor (Level A) 2, 3.
- Topiramate is also considered clinically useful, but only for doses higher than 200 mg/day 2.
- Alprazolam, atenolol, gabapentin, sotalol, and topiramate are probably effective in reducing limb tremor (Level B) 3.
- Clonazepam, clozapine, nadolol, and nimodipine possibly reduce limb tremor (Level C) 3.
Surgical Treatments
- Unilateral Ventralis intermedius thalamic DBS, radiofrequency thalamotomy, and MRI-guided focused ultrasound thalamotomy are considered possibly useful for treating essential tremor 2.
- Deep brain stimulation (DBS) and thalamotomy are highly efficacious in reducing tremor, but carry a small risk of major complications 3, 5.
- Botulinum toxin A may reduce hand tremor, head tremor, and voice tremor, but is associated with dose-dependent side effects such as hand weakness, breathiness, hoarseness, and swallowing difficulties 3, 5.
Treatment Patterns and Outcomes
- A retrospective analysis of 1468 patients with essential tremor found that primidone was the most used medication, followed by propranolol, topiramate, and gabapentin 6.
- Medication response was available for 1030 prescriptions, with 13.4% discontinued due to side effects and 17.5% ineffective 6.
- Botulinum toxin injections and deep brain stimulation surgery were used in 4.8% and 3.8% of patients, respectively 6.