What treatment is recommended for a patient with essential tremor and a history of hypertension?

From the Guidelines

For a patient with essential tremor and a history of hypertension, the recommended first-line treatment is propranolol, a beta-blocker, as it can effectively manage both the tremor and hypertension, according to the most recent evidence from 2022 1.

Treatment Approach

The treatment approach for essential tremor and hypertension involves a combination of pharmacological and lifestyle modifications.

• Start with a low dose of propranolol, 20 mg twice daily, and gradually increase to 40 mg twice daily as needed, up to a maximum of 320 mg per day divided into doses.
• If propranolol is not tolerated or contraindicated, consider primidone starting at 25 mg at bedtime, increasing gradually to 250 mg three times daily as needed.
• Additionally, implement lifestyle modifications such as reducing caffeine intake, getting adequate sleep, and managing stress.

Rationale

Beta-blockers, such as propranolol, work by blocking the effects of adrenaline and other stress hormones, which helps reduce tremors and lower blood pressure.

• The 2024 ESC guidelines for the management of elevated blood pressure and hypertension recommend beta-blockers as a first-line treatment for hypertension in certain cases, such as when there are other compelling indications for their use 1.
• However, the most recent and highest quality study on the treatment of essential tremor and hypertension, from 2022, supports the use of propranolol as a first-line treatment 1.

Monitoring and Follow-up

Monitor the patient regularly for efficacy and potential side effects, adjusting the dosage as necessary.

• If symptoms persist or worsen, consider referral to a neurologist for further evaluation and management.
• Regular monitoring of blood pressure and tremor symptoms is crucial to ensure the effectiveness of the treatment and to make any necessary adjustments.

From the Research

Treatment Options for Essential Tremor

The treatment of essential tremor (ET) depends on the severity, location, and risk-benefit ratios of the tremor 2. For patients with a history of hypertension, the following treatment options are recommended:

• Primidone and propranolol are considered first-line medications for the treatment of ET 3, 4, 5
• Other medications that may be effective in reducing tremor include topiramate, alprazolam, and botulinum toxin type A 4, 2
• Surgical procedures, such as unilateral Ventralis intermedius thalamic DBS, radiofrequency thalamotomy, and MRI-guided focused ultrasound thalamotomy, may be considered for patients with medically refractory tremor 4, 2

Considerations for Patients with Hypertension

When treating patients with ET and a history of hypertension, it is essential to consider the potential interactions between the medications used to treat ET and the patient's hypertension. Propranolol, a beta-blocker, may be beneficial for patients with hypertension, but its use should be carefully monitored to avoid exacerbating the condition 4, 5.

Additional Treatment Options

Other treatment options that may be effective for ET include:

• Ethanol, which has been shown to be an effective suppressor of ET 6
• Benzodiazepines, which may be useful in reducing tremor 2, 6
• Gabapentin, levetiracetam, and zonisamide, which may be effective in some cases 2
• Botulinum toxin injections, which may be effective for certain tremor patterns, such as wrist flexion/extension and head tremor 2