What medications are used to treat tremor?

Medications for Tremor Management

Beta-blockers, particularly propranolol, are the first-line treatment for essential tremor, typically starting at 40 mg twice daily with a maximum dose of 240 mg daily. 1

First-Line Medications

• Propranolol: The most established beta-blocker for tremor treatment

  • Dosage: Start at 40 mg twice daily, maximum 240 mg daily
  • Efficacy: Improves tremor in approximately 50% of patients
  • Benefits: May provide dual benefit for patients with comorbid hypertension or migraine

• Alternative beta-blockers when propranolol is not tolerated:

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

Second-Line Medications

• Primidone: Can be used alone or in combination with propranolol for enhanced effect 2

  • Often used when beta-blockers provide inadequate control

• Topiramate: Supported by clinical trials as effective for essential tremor 3

  • Particularly useful when first-line treatments fail

• Gabapentin: 300-2400 mg daily, divided into three doses 1

  • Especially beneficial for patients with comorbid neuropathic pain

Other Medication Options

• Benzodiazepines (e.g., clonazepam):

  • Useful for tremor exacerbated by stress and anxiety
  • Should be used cautiously due to risk of dependency 2

• Botulinum toxin injections:

  • Particularly effective for head or voice tremor
  • Not widely used for hand tremor due to risk of hand weakness 2

Treatment Algorithm Based on Tremor Type

Essential Tremor

1. Start with propranolol (40 mg twice daily)
2. If inadequate response or intolerance, try alternative beta-blockers
3. Consider primidone if beta-blockers fail
4. For refractory cases, consider combination therapy (beta-blocker + primidone)
5. Third-line options: topiramate, gabapentin, or benzodiazepines

Parkinsonian Tremor

• Carbidopa-levodopa remains the first-line treatment 4
• Available in various formulations including orally disintegrating tablets 5

Cerebellar Tremor

• Limited effective pharmacological options
• Isoniazid may control cerebellar tremor associated with multiple sclerosis 4

Orthostatic Tremor

• Clonazepam is often effective 4
• Gabapentin may also provide relief 3

Treatment Considerations

• Medication overuse: Limit use of benzodiazepines to avoid dependency
• Identify and discontinue tremor-exacerbating medications when possible (e.g., SSRIs, stimulants, caffeine) 1
• Elderly patients: Start with lower doses of propranolol (10-20 mg twice daily) and titrate slowly 1
• Treatment failure: Consider surgical options (deep brain stimulation or thalamotomy) for incapacitating tremor unresponsive to medications 2

Monitoring and Follow-up

• Assess response to treatment using standardized tremor rating scales
• Monitor for common side effects:
  • Beta-blockers: bradycardia, hypotension, fatigue, bronchospasm
  • Primidone: sedation, dizziness, ataxia
  • Topiramate: cognitive effects, paresthesia, weight loss

Surgical Options for Refractory Cases

When medications fail to adequately control disabling tremor, surgical interventions may be considered:

• Deep brain stimulation (DBS) of the thalamus: Provides approximately 90% tremor control with fewer complications than ablative procedures 2
• Thalamotomy: Effective but with higher risk of permanent adverse effects 3

These surgical options should be reserved for patients with severe, medication-refractory tremor that significantly impacts quality of life.