What medications are used to treat essential tremors?

Medications for Essential Tremor

Propranolol is the first-line medication for essential tremor, with approximately 50% efficacy in reducing tremor severity and improving quality of life. 1

First-Line Medications

Beta-Blockers

• Propranolol:

  • Mechanism: Blocks beta-1 and beta-2 adrenergic receptors
  • Dosing: Start at 40 mg twice daily, can be titrated up to maximum 240 mg daily 1
  • For mild, situational tremor: 20-40 mg as needed before anxiety-inducing situations
  • Efficacy: Improves tremor in approximately 50% of patients 2
  • Special populations: In elderly patients, start with lower doses (10-20 mg twice daily) and titrate slowly 1

• Alternative beta-blockers (if propranolol not tolerated):

  • Metoprolol: Less effective but better option for patients with respiratory concerns
  • Atenolol: Fewer central nervous system effects
  • Nadolol: Alternative for patients with contraindications to propranolol 1

Anticonvulsants

• Primidone:
  • Can be used as first-line alternative to propranolol
  • Dosing: Start low (50 mg) and gradually increase to 250 mg daily 3
  • Side effects: Higher rate of acute adverse reactions (32%) compared to propranolol (8%) 3
  • Can be combined with propranolol if either medication alone provides inadequate control 2

Second-Line Medications

• Gabapentin:

  • Dosage: 300-2400 mg daily divided into three doses
  • Particularly effective for patients with comorbid neuropathic pain 1

• Topiramate:

  • May provide benefit when first-line agents fail 2

• Benzodiazepines:

  • Clonazepam can be used when primidone and propranolol don't provide adequate control
  • Useful for patients with stress-induced tremor exacerbations 2
  • Caution: Risk of dependence with long-term use

Treatment Algorithm

1. Initial Assessment:

   • If tremor causes functional disability, initiate treatment
   • If tremor is only disabling during stress/anxiety, consider as-needed propranolol

2. First-Line Treatment:

   • Start with propranolol 40 mg twice daily OR
   • Primidone starting at 50 mg and gradually increasing

3. Inadequate Response:

   • Combine propranolol and primidone
   • If side effects occur with propranolol, try alternative beta-blockers

4. Refractory Cases:

   • Add benzodiazepines (clonazepam)
   • Consider gabapentin or topiramate
   • For persistent disabling tremor despite medication trials, consider surgical options (deep brain stimulation or thalamotomy) 2

Special Considerations

• Head or voice tremor: Consider botulinum toxin injections 2
• Comorbid hypertension: Beta-blockers provide dual benefit 1
• Comorbid migraine: Propranolol, metoprolol, and timolol are effective for both conditions 1

Treatment Efficacy and Monitoring

• Currently available medications improve tremor in approximately 50% of patients 2
• Tolerance to drug effect may occur with chronic treatment in 12.5% of patients with propranolol and 13.0% with primidone 3
• Surgical options (deep brain stimulation or thalamotomy) provide adequate tremor control in approximately 90% of patients with refractory tremor 2

Medications with Limited Evidence

• Carbonic anhydrase inhibitors (e.g., methazolamide)
• Phenobarbital
• Calcium channel antagonists (e.g., nimodipine)
• Isoniazid, clonidine, clozapine, and mirtazapine 2
• SSRIs including escitalopram are not recommended due to lack of evidence 1

Remember that no current medication can cure essential tremor or slow its progression. Treatment goals focus on reducing functional disability and improving quality of life.