What is the diagnosis and treatment for symptoms including tremors, hand tremors, diplopia (double vision), nystagmus (involuntary eye movement), and neck pain?

From the Guidelines

The symptoms of tremors, hand tremors, diplopia, nystagmus, and neck pain suggest a potential neurological disorder, and the most recent and highest quality study 1 recommends a thorough neurological evaluation to establish a definitive diagnosis. The diagnosis and treatment of these symptoms depend on the underlying cause, which could be multiple sclerosis (MS), essential tremor, cervical dystonia, or medication side effects.

• A thorough neurological evaluation including MRI imaging of the brain and spinal cord, lumbar puncture to examine cerebrospinal fluid, and blood tests to rule out other conditions is necessary to determine the cause of the symptoms.
• For MS, first-line treatments include disease-modifying therapies such as interferon beta (Avonex, Rebif), glatiramer acetate (Copaxone), or oral medications like dimethyl fumarate (Tecfidera) or fingolimod (Gilenya) 1.
• Symptom management is also important:
  • Tremors may be treated with propranolol (20-40mg twice daily) or primidone (starting at 50mg daily, increasing gradually) 1.
  • Diplopia might require temporary use of prism glasses or chemodenervation (botulinum toxin) of an antagonist extraocular muscle 1.
  • Neck pain could be addressed with physical therapy and pain management including NSAIDs like ibuprofen (400-800mg three times daily) 1. It is essential to note that the treatment should be individualized based on the patient's specific condition and symptoms, and a neurologist should establish a definitive diagnosis before beginning treatment. The underlying mechanism often involves demyelination of nerve fibers or disruption of neural pathways controlling motor function and eye movement coordination.
• Neuroimaging should be considered in all young patients or in any patient manifesting other cranial neuropathies, other neurologic change or elevated IOP, or signs of elevated intracranial pressure, or if there are no compelling vasculopathic risk factors 1. The goal of treatment is to eliminate diplopia in the primary position and to create a reasonable field of single binocular vision, and patients should be advised that they may continue to have diplopia in extreme lateral gaze due to the difficulty in balancing ductions given the underlying neurological deficit.

From the FDA Drug Label

The most common adverse reactions with gabapentin in combination with other antiepileptic drugs in patients >12 years of age, not seen at an equivalent frequency among placebo-treated patients, were somnolence, dizziness, ataxia, fatigue, and nystagmus Other reactions in more than 1% of patients but equally or more frequent in the placebo group included pain, tremor, neuralgia, back pain, dyspepsia, dyspnea, and flu syndrome Nervous System Dizziness 28 8 Somnolence 21 5 Ataxia 3 0 Thinking abnormal 3 0 Abnormal gait 2 0 Incoordination 2 0 Special Senses Amblyopiaa 3 1 Conjunctivitis 1 0 Diplopia 1 0 Nervous System Somnolence 19 9 Dizziness 17 7 Ataxia 13 6 Nystagmus 8 4 Tremor 7 3

The symptoms described, including tremors, hand tremors, diplopia (double vision), nystagmus (involuntary eye movement), and neck pain, could be related to a neurological condition.

• Diplopia and nystagmus are listed as adverse reactions in the gabapentin drug label 2.
• Tremor is also mentioned as an adverse reaction in the gabapentin drug label 2. However, the FDA drug label does not provide a clear diagnosis for these symptoms. Gabapentin is used to treat partial onset seizures and postherpetic neuralgia, but the symptoms described do not necessarily indicate these conditions. A conservative clinical decision would be to consult a healthcare professional for a proper diagnosis and treatment plan.

From the Research

Diagnosis and Treatment of Tremors, Diplopia, Nystagmus, and Neck Pain

The symptoms described, including tremors, hand tremors, diplopia (double vision), nystagmus (involuntary eye movement), and neck pain, can be associated with various neurological conditions.

• Tremors: Can be classified into different types, including essential tremor, parkinsonian tremor, and others. The treatment for tremors often depends on the underlying cause and can include medications such as propranolol, primidone, and gabapentin, as well as surgical options like deep brain stimulation 3.
• Diplopia and Nystagmus: These symptoms can be related to conditions affecting the brainstem, cerebellum, or the nerves controlling eye movements. In the context of multiple sclerosis, gabapentin has been shown to be effective in treating acquired nystagmus, suggesting a potential role in managing these symptoms 4.
• Neck Pain: Can be associated with various conditions, including musculoskeletal issues, cervical dystonia, or as a side effect of treatments for other conditions.

Treatment Options

• Medications: Gabapentin has been found effective in treating acquired nystagmus in multiple sclerosis patients 4. For tremors, propranolol and primidone are considered effective, while alprazolam, atenolol, gabapentin, sotalol, and topiramate are probably effective 3.
• Botulinum Toxin: Has been used to treat head tremor and hand tremor, with studies showing improvement in symptoms, though it can be associated with side effects like dysphagia, neck weakness, and local pain 5, 6.
• Surgical Options: Deep brain stimulation and thalamotomy are considered highly efficacious in reducing tremor, though they carry risks of major complications 3.

Considerations for Diagnosis

Given the complexity and variety of potential diagnoses, a thorough neurological examination and diagnostic workup are essential to determine the underlying cause of these symptoms. This may involve a combination of clinical assessments, imaging studies, and potentially, electrophysiological tests to evaluate the function of the nerves and muscles involved.

The recognition of rare forms of tremor and tremors occurring in other neurological disorders is crucial for making a correct diagnosis and guiding appropriate treatment 7. Each patient's condition should be evaluated individually, considering the specific symptoms, medical history, and response to previous treatments to develop an effective management plan.