What are the treatment options for mouth tremors?

Treatment Options for Mouth Tremors

For mouth tremors, botulinum toxin injections into the affected muscles are the most effective first-line treatment, providing significant improvement in symptoms while maintaining quality of life. 1

Classification and Assessment

Before initiating treatment, proper classification of the mouth tremor is essential:

• Determine if the tremor is:

  • Essential tremor affecting the mouth/jaw (4-8 Hz, postural and kinetic)
  • Parkinsonian tremor (3-5 Hz, primarily resting)
  • Dystonic tremor (irregular, position-specific)
  • Functional tremor (variable, distractible)
  • Drug-induced tremor (related to medications)

• Evaluate tremor characteristics:

  • At rest vs. with sustained posture vs. during movement
  • Associated neurological findings (bradykinesia, rigidity)
  • Impact on speech, eating, and quality of life

First-Line Treatment

Botulinum Toxin Injections

• Primary recommendation: Botulinum toxin injections into affected muscles 1
  • Particularly effective for head and voice tremor, which can be applied to mouth tremor
  • Provides targeted relief with minimal systemic side effects
  • Dosing must be individualized based on muscle involvement
  • Effects typically last 3-4 months, requiring repeat injections

Pharmacological Options

For patients who cannot receive botulinum toxin or as adjunctive therapy:

1. Beta-blockers:

   • Propranolol 40mg twice daily (up to 240mg daily) 2, 3
   • Alternative beta-blockers if propranolol not tolerated:
     • Metoprolol (less effective but safer with respiratory concerns)
     • Atenolol (fewer central nervous system effects)
     • Nadolol (alternative option)

2. Anticonvulsants:

   • Primidone (start at 12.5-25mg and gradually titrate) 3, 4
   • Gabapentin (300-2400mg daily divided into three doses) 2
   • Topiramate (shown efficacy in controlled trials) 5, 4

3. Benzodiazepines:

   • Alprazolam (0.75mg daily) - particularly useful for elderly patients 2
   • Clonazepam - can provide benefit when other medications fail 3

Treatment Algorithm

1. Start with botulinum toxin injections if tremor is moderate to severe and affecting quality of life 1
2. If botulinum toxin is contraindicated or ineffective:
   • Try propranolol (starting at 40mg twice daily) 2, 3
   • OR primidone (starting at low doses of 12.5-25mg) 3, 4
3. If single-agent therapy is inadequate:
   • Combine propranolol and primidone 3
   • OR add gabapentin or topiramate 2, 5
4. For refractory cases:
   • Consider MRgFUS thalamotomy (56% tremor improvement maintained at 4 years) 6, 2
   • Consider Deep Brain Stimulation (90% tremor control) 3, 5

Special Considerations

Functional Tremor

• For functional mouth tremor (psychogenic):
  • Speech restructuring and fluency shaping techniques 6
  • Slowing rate of speech and emphasizing speech naturalness
  • Cognitive behavioral therapy addressing abnormal illness beliefs 6
  • Focus on normal movements and sounds, distracting from abnormal patterns 6

Burning Mouth Syndrome

• If mouth tremor is associated with burning mouth syndrome:
  • Exclude secondary causes (candidiasis, mucosal lesions, hematological disorders)
  • Provide reassurance that condition will not worsen
  • Consider neuropathic pain medications 6
  • Cognitive behavioral therapy may be beneficial 6

Drug-Induced Tremor

• If tremor is medication-induced:
  • Identify and discontinue the offending medication if possible 2, 7
  • Common culprits: SSRIs/SNRIs, amitriptyline, lithium, valproate, dopamine antagonists 7
  • Drug-induced tremor usually resolves once the offending medication is discontinued 7

Monitoring and Follow-up

• Assess treatment response using standardized tremor rating scales

• Monitor for side effects:

  • For botulinum toxin: weakness, dysphagia, dysarthria 1
  • For beta-blockers: bradycardia, hypotension, fatigue, bronchospasm 2
  • For primidone: sedation, dizziness, ataxia 2

• For surgical interventions, be aware that:

  • MRgFUS thalamotomy has a lower complication rate (4.4%) compared to radiofrequency thalamotomy (11.8%) and DBS (21.1%) 6
  • Serious adverse events with MRgFUS are rare (1.6%) 6

Remember that approximately 50% of patients respond to pharmacological treatments 3, while surgical options can provide adequate tremor control in approximately 90% of patients 3, 5.