From the Guidelines
The management of benign essential tremor (ET) should primarily involve pharmacotherapy with propranolol as a first-line treatment, given its long-standing use and effectiveness in reducing tremor amplitude, as noted in a 2022 study published in Hypertension 1. The use of propranolol for essential tremor has been established for over 40 years, with other beta-blockers like metoprolol also being potentially effective depending on the individual case, as indicated in the same study 1.
Key Considerations
- Propranolol is typically started at a dose of 20-40 mg twice daily and can be titrated up to 240 mg daily as needed.
- Lifestyle modifications are crucial and include reducing caffeine intake, avoiding tremor-triggering medications, using weighted utensils, and employing stress management techniques.
- For patients who do not respond adequately to propranolol, alternative pharmacological options may be considered, although the most recent and highest quality evidence prioritizes propranolol as the first-line treatment.
Additional Therapies
- In cases where pharmacotherapy is ineffective, surgical interventions such as deep brain stimulation or botulinum toxin injections for focal tremors may be considered, but these are not the primary approach based on the latest evidence 1.
- Regular follow-up is essential to monitor treatment efficacy and adjust therapy as needed, considering the progressive nature of essential tremor over time.
From the Research
Management of Benign Essential Tremor (ET)
The management of benign essential tremor (ET) involves a range of treatment options, including medications, surgical procedures, and other forms of therapy.
- Treatment is recommended if the tremor causes functional disability 2, 3.
- The currently available medications can improve tremor in approximately 50% of the patients 2.
Medications
The first-line medications for the treatment of ET are primidone and propranolol 2, 3.
- If either primidone or propranolol do not provide adequate control of the tremor, then the medications can be used in combination 2.
- Other medications that may be helpful include gabapentin, topiramate, benzodiazepines, and botulinum toxin injections into the muscles 2, 4, 5, 6.
- Botulinum toxin injections are effective in some tremor patterns, especially wrist flexion/extension and head tremor 6.
Surgical Options
Surgical options are usually considered if the patient still has disabling tremor after medication trials 2.
- Surgical options include thalamotomy and deep brain stimulation of the thalamus 2, 4, 5, 6.
- These surgical options provide adequate tremor control in approximately 90% of the patients 2.
- Deep brain stimulation and thalamotomy have been shown to have comparable efficacy but fewer complications have been reported with deep brain stimulation 2.