What are the treatment options for tremors?

Treatment Options for Essential Tremor

First-line treatment for essential tremor includes propranolol (40 mg twice daily, up to 240 mg daily) or primidone as monotherapy, which can improve tremor in approximately 50% of patients. 1

Pharmacological Treatment Algorithm

First-Line Medications

• Beta-blockers:

  • Propranolol: 40 mg twice daily, maximum 240 mg daily 1
  • Alternative beta-blockers for patients with contraindications to propranolol:
    • Metoprolol: For patients with respiratory concerns
    • Atenolol: Fewer central nervous system effects
    • Nadolol: Alternative option 1

• Anticonvulsants:

  • Primidone: Alternative first-line option 1
  • Gabapentin: 300-2400 mg daily divided into three doses; particularly effective for patients with comorbid neuropathic pain 1, 2

Second-Line Medications

• Combination therapy with first-line agents if monotherapy is inadequate 1
• Topical agents for localized tremor:
  • Topical lidocaine 5% patches may be helpful for tremor-associated pain 3

Surgical Options for Medication-Refractory Cases

For patients with significant functional disability who don't respond adequately to medications:

1. MR-guided focused ultrasound (MRgFUS) thalamotomy 1
2. Deep brain stimulation 1, 4

Tremor Classification and Treatment Considerations

Types of Tremors and Specific Treatments

• Postural tremor (4-8 Hz): Occurs when maintaining position against gravity

  • Responds well to propranolol 1, 5

• Kinetic tremor: Occurs during voluntary movement

  • Often responds to primidone or gabapentin 1, 2

• Rest tremor (4-6 Hz): Occurs when body part is relaxed and supported

  • If parkinsonian in origin: Carbidopa-levodopa is first-line 6

Evidence on Treatment Efficacy

Propranolol has been shown to be effective for essential tremor in multiple studies, with improvement observed in all patients in controlled trials 5. Interestingly, the clinical effect does not correlate with plasma propranolol levels, suggesting that even low doses may be effective for some patients 7.

A comparative study between gabapentin (400 mg three times daily) and propranolol (40 mg three times daily) demonstrated that both medications had comparable efficacy in reducing essential tremor 2. This provides an alternative for patients who cannot tolerate beta-blockers.

Important Clinical Considerations

• Monitoring: Assess for medication side effects, particularly:

  • Propranolol: Bradycardia, hypotension, bronchospasm
  • Primidone: Sedation, dizziness, nausea
  • Gabapentin: Somnolence, dizziness, peripheral edema

• Common pitfalls to avoid:

  • Misdiagnosing dystonic tremor as essential tremor
  • Overlooking drug-induced causes of tremor
  • Inadequate medication dosing before declaring treatment failure
  • Not considering surgical options for severe, medication-refractory tremors 1

• Patient counseling:

  • Exercise caution while driving or operating machinery during treatment
  • Report significant daytime sleepiness or episodes of falling asleep during activities 6
  • Avoid abrupt discontinuation of medications, especially if also taking neuroleptics 6

For parkinsonian tremor specifically, combination therapy with carbidopa and levodopa remains the first-line approach 6, 4, but this is distinct from the treatment of essential tremor.