What is essential tremor?

From the Guidelines

Essential tremor should be treated with propranolol as the first-line medication option, given its established efficacy over 40 years of use, as noted in a 2022 study published in Hypertension 1. The treatment of essential tremor typically involves a combination of lifestyle modifications and medication. Lifestyle changes such as avoiding caffeine and stress can help alleviate symptoms.

• Medication options are considered when lifestyle modifications are insufficient to control the tremors.
• Propranolol, a beta-blocker, has been widely used for over 40 years to treat essential tremor, with other beta-blockers like metoprolol also being effective in certain cases, as indicated in the 2022 study 1.
• The dosage of propranolol can vary, but it is often started at a low dose and gradually increased as needed and tolerated.
• Other first-line medication options may include primidone, which can also reduce tremor amplitude.
• For patients who do not respond adequately to first-line treatments, second-line options such as topiramate, gabapentin, or benzodiazepines like clonazepam may be considered.
• In severe cases where medication is ineffective, surgical interventions like deep brain stimulation or botulinum toxin injections may be explored to improve quality of life.
• The goal of treatment is to reduce the amplitude and frequency of tremors, thereby improving the patient's ability to perform daily activities and enhancing their overall quality of life, which is a critical consideration in the management of essential tremor, as supported by the 2022 study in Hypertension 1.

From the Research

Definition and Characteristics of Essential Tremor

• Essential tremor is a chronic and progressive neurologic disease characterized by a 4-12Hz kinetic tremor, occurring during voluntary movements 2.
• It is the most common cause of tremor involving upper limbs, head, and voice 3.
• Patients may exhibit a range of other tremors, including postural, rest, and intention tremors, as well as additional motor features such as mild gait ataxia and mild dystonia 2.

Treatment Options for Essential Tremor

• The first line of treatment for limb tremor is pharmacotherapy with propranolol or primidone, which can reduce tremor severity by half 3.
• Other pharmacological treatments that may be effective include topiramate, alprazolam, and botulinum toxin type A 4, 5.
• Surgical interventions, such as deep brain stimulation, magnetic resonance-guided focused ultrasound, and thalamotomy, may be considered for medication-refractory and functionally disabling tremor 4, 5, 3.
• Botulinum toxin injections may be efficacious for limb, voice, and head tremor, but are associated with side effects 3.

Efficacy of Treatment Options

• Propranolol and primidone are classified as clinically useful for limb tremor in essential tremor 4.
• Topiramate, alprazolam, and botulinum toxin type A are classified as possibly useful for limb tremor in essential tremor 4, 5.
• Unilateral Ventralis intermedius thalamic DBS, radiofrequency thalamotomy, and MRI-guided focused ultrasound thalamotomy are considered possibly useful for limb tremor in essential tremor 4.
• Deep brain stimulation and thalamotomy are highly efficacious in reducing tremor, but carry a small risk of major complications 5, 6.

Limitations and Future Directions

• There is a need to improve study design in essential tremor and overcome the limitation of small sample sizes, cross-over studies, short-term follow-up studies, and use of nonvalidated clinical scales 4.
• Additional prospective, double-blind, placebo-controlled trials are needed to better determine the efficacy and side effects of pharmacologic and surgical treatments of ET 5.
• Recent research has increasingly placed the seat of the disease in the cerebellum and cerebellar system, indicating that this progressive disorder is likely degenerative 2.