What are the treatments for orthostatic tremors?

Treatment Options for Orthostatic Tremor

Clonazepam is the first-line pharmacological treatment for orthostatic tremor, with gabapentin as an effective alternative for patients who don't respond to or cannot tolerate clonazepam. 1

Understanding Orthostatic Tremor

Orthostatic tremor (OT) is a rare neurological disorder characterized by:

• High-frequency tremor (13-18 Hz) in the legs that occurs when standing
• Rapid relief of symptoms when sitting, walking, or lying down
• Normal neurological examination except for unsteadiness while standing
• Typically begins in the sixth decade of life
• Can be highly disabling despite its relatively benign appearance

First-Line Pharmacological Treatments

1. Clonazepam

• Most commonly prescribed medication for OT
• Shows the highest efficacy in literature reviews 2
• Dosage should be started low and titrated based on response
• Main limitation: sedation and potential for dependence

2. Gabapentin

• Highly effective alternative with 60-80% improvement reported in patients 3
• Effective dosage ranges from 300-1800 mg/day (mean 1030 mg/day)
• Particularly valuable for patients who don't respond to clonazepam
• Side effects are generally mild, transient, and dose-related 3
• Can be used as first-line therapy when clonazepam is contraindicated

3. Perampanel

• Recent evidence suggests high efficacy but also higher adverse effect profile 2
• May be considered when other medications fail

Second-Line Treatments

1. Primidone

• May be effective in cases resistant to first-line treatments 1
• Start at low doses to minimize side effects

2. Dopaminergic Medications

• Some patients may respond to dopaminergic drugs
• Consider in patients with concurrent parkinsonian features 4

Surgical Intervention for Medication-Resistant Cases

Deep Brain Stimulation (DBS)

• Bilateral thalamic (Vim) DBS has shown significant improvement in medication-refractory cases 5
• Should be considered for patients with disabling symptoms despite optimal medical therapy
• Reports indicate continued benefit at long-term follow-up (30 months) 5

Non-Pharmacological Approaches

Lifestyle Modifications

• Avoid prolonged standing
• Use of walking aids or supports
• Compression stockings may help some patients
• Physical counterpressure maneuvers (leg crossing, muscle tensing) may provide temporary relief

Treatment Algorithm

1. Initial Assessment:

   • Confirm diagnosis with surface electromyography showing 13-18 Hz tremor
   • Rule out secondary causes of orthostatic tremor

2. First-Line Treatment:

   • Start with clonazepam at low dose, gradually titrate
   • If ineffective or poorly tolerated, switch to gabapentin starting at 300 mg/day

3. Second-Line Treatment:

   • Add or switch to primidone or perampanel if first-line treatments fail
   • Consider trial of dopaminergic medications, especially with parkinsonian features

4. Refractory Cases:

   • Evaluate for bilateral thalamic DBS in patients with:
     • Disabling symptoms
     • Failure of multiple medication trials
     • No contraindications to surgery

Important Considerations

• Pharmacological treatments are often insufficient for complete symptom control 2
• Combination therapy may be necessary in some patients
• Regular follow-up is essential to monitor efficacy and side effects
• The condition can be progressive in up to 15% of patients, requiring treatment adjustments over time 5

Common Pitfalls to Avoid

1. Misdiagnosis as anxiety or psychogenic disorder due to normal examination findings
2. Failure to confirm diagnosis with electromyography
3. Inadequate dosing of medications before declaring treatment failure
4. Not considering DBS in appropriate medication-refractory cases
5. Overlooking the significant impact on quality of life despite the seemingly benign nature of the condition

While orthostatic tremor can be challenging to treat, a systematic approach using the medications with the best evidence for efficacy can significantly improve patients' quality of life and functional status.