What is the treatment for tremors?

Treatment of Tremors

Beta-blockers, particularly propranolol, are the first-line treatment for most tremors, especially essential tremor, while specific treatments should be tailored to the underlying tremor type. 1

Classification of Tremors

Proper treatment begins with correct classification of the tremor:

• Rest tremor: Occurs when body part is at rest (e.g., Parkinson's disease)
• Action tremor:
  • Postural tremor: Occurs when maintaining a position against gravity
  • Kinetic tremor: Occurs during voluntary movement
  • Task-specific tremor: Appears during specific activities

First-Line Treatments by Tremor Type

Essential Tremor (Most Common)

• First-line: Propranolol (beta-blocker) 1, 2
  • Effective in approximately 50% of cases 3
  • Dosage must be individualized based on response
• Alternative first-line: Primidone 4

Parkinsonian Tremor

• First-line: Anticholinergics and levodopa/carbidopa combination 4
• Adjunctive therapy: Beta-blockers may help with action component of tremor 1

Functional (Psychogenic) Tremor

• Address underlying psychological factors
• Behavioral techniques and entrainment strategies 1
• Techniques include:
  • Diaphragmatic breathing
  • Progressive muscle relaxation
  • Sensory grounding techniques 1

Dystonic Tremor

• Botulinum toxin injections 3
• May also respond to anticholinergics

Treatment Algorithm

1. Identify tremor type based on:

   • Position when tremor occurs (rest vs. action)
   • Frequency and amplitude
   • Associated symptoms or conditions

2. For mild tremors:

   • Non-pharmacological approaches first
   • Avoid tremor triggers (caffeine, stress)
   • Consider as-needed medication for situational use

3. For moderate tremors:

   • Essential tremor: Start propranolol 20-40 mg twice daily, titrate as needed 5
   • Parkinsonian tremor: Begin with anticholinergics or levodopa/carbidopa
   • Dystonic tremor: Consider botulinum toxin injections

4. For severe or refractory tremors:

   • Consider surgical options like deep brain stimulation for essential tremor 5
   • For polymorphic VT with tremor: IV beta-blockers are useful and improve mortality 1

Specific Intervention Strategies for Functional Tremor

• Superimpose alternative rhythms on top of existing tremor
• For unilateral tremor: use unaffected limb to dictate new rhythm
• Assist in muscle relaxation to prevent co-contraction
• Use gross rather than fine movements for retraining 1

Common Pitfalls and Caveats

1. Misdiagnosis: Isolated head tremor is more likely dystonic than essential tremor 3

2. Medication contraindications:

   • Beta-blockers should be used with caution in patients with:
     • Obstructive pulmonary disease
     • Congestive heart failure 1
     • Diabetes (may mask hypoglycemia symptoms) 1

3. Treatment resistance:

   • Only about 50% of essential tremor patients respond adequately to medications 3
   • Consider combination therapy or surgical options for refractory cases

4. Adaptive equipment concerns:

   • Avoid aids and equipment in early/acute phases of functional tremor
   • If necessary, use minimalist approach with plan to progress toward independence 1

5. Drug interactions:

   • Avoid combining AV nodal blocking agents with longer duration of action
   • The combination can cause profound bradycardia 1

Remember that tremor treatment should be directed at the underlying condition whenever possible, with symptomatic treatment provided when necessary.