From the Guidelines
The acute management of tremors involves identifying and addressing the underlying cause while providing symptomatic relief, with benzodiazepines like lorazepam or diazepam being first-line treatments for emergency tremor control, and propranolol or primidone for essential tremor, as supported by recent studies 1.
Key Considerations
- Identifying the underlying cause of the tremor is crucial for effective management, whether it be essential tremor, Parkinsonian tremor, or functional tremor.
- For emergency tremor control, benzodiazepines are preferred due to their rapid onset of action, with lorazepam (1-2mg IV or oral) or diazepam (5-10mg) being commonly used options.
- In cases of essential tremor, propranolol (20-40mg twice daily) or primidone (starting at 25mg at bedtime, gradually increasing) can be effective, as noted in a recent study on beta-blocker treatment 1.
- For functional tremors, occupational therapy strategies such as superimposing alternative rhythms, relaxing muscles, and using gross movements can be helpful, as outlined in a 2020 study on occupational therapy consensus recommendations 1.
Treatment Options
- Benzodiazepines: lorazepam (1-2mg IV or oral), diazepam (5-10mg)
- Beta-blockers: propranolol (20-40mg twice daily)
- Primidone: starting at 25mg at bedtime, gradually increasing
- Dopaminergic medications: levodopa/carbidopa (starting at 25/100mg three times daily) for Parkinsonian tremors
Supportive Measures
- Hydration
- Temperature control
- Calm environment
- Addressing precipitating factors: correcting electrolyte abnormalities, treating infections, discontinuing tremor-inducing medications, and managing hypoglycemia or thyrotoxicosis when present.
From the FDA Drug Label
In acute alcohol withdrawal, diazepam may be useful in the symptomatic relief of acute agitation, tremor, impending or acute delirium tremens and hallucinosis The acute management of tremors may include diazepam (PO) for symptomatic relief, specifically in the context of acute alcohol withdrawal 2.
- Key indication: Acute alcohol withdrawal
- Symptomatic relief: Tremor, acute agitation, impending or acute delirium tremens, and hallucinosis Note that this is a specific use case and may not be generalizable to all types of tremors.
From the Research
Acute Management of Tremors
The acute management of tremors involves a variety of approaches, including:
- Correct diagnosis to determine the underlying cause of the tremor 3, 4, 5, 6, 7
- First-line medications such as primidone, propranolol, and topiramate for essential tremor 3, 4, 7
- Alternative therapies, including surgery or injections of botulinum toxin, for patients with medically refractory tremor 3, 4, 7
- Deep brain stimulation (DBS) of the thalamic and subthalamic region for severe tremors 4, 7
- Focused ultrasound thalamotomy as a new therapy for essential tremor 4
- Botulinum toxin injections for midline tremors, dystonic tremor, and primary writing tremor 6, 7
Treatment Approaches
Treatment approaches for tremors vary depending on the severity and type of tremor, and may include:
- Occupational therapy, speech therapy, and psychotherapy for mild to moderate tremor severity 4
- Symptomatic treatment with medications such as propranolol, primidone, and topiramate for essential tremor 3, 4, 7
- Stereotactic thalamotomy or thalamic stimulation as a last resort for severe tremors 5
- Radiosurgery, although not well established, as a potential treatment option for essential tremor 4
Classification and Diagnosis
Tremors can be classified based on their clinical features, such as:
- Resting tremor, postural tremor, and kinetic tremor 5, 6
- Frequency, amplitude, and body part involved 5, 6
- Underlying cause, such as essential tremor, Parkinson's disease, or dystonia 3, 4, 5, 6, 7 Accurate diagnosis is essential to determine the appropriate treatment approach for each patient 3, 4, 5, 6, 7