What are the treatment options for tremors?

Treatment Options for Tremors

The first-line pharmacological treatments for essential tremor include propranolol, primidone, and topiramate, which can improve tremor in approximately 50% of patients. 1

Types of Tremors and Classification

Tremors can be classified into four main types:

• Rest tremors (4-6 Hz): Occur when body part is relaxed and supported
• Postural tremors (4-8 Hz): Occur when maintaining position against gravity
• Kinetic tremors: Occur during voluntary movement
• Isometric tremors: Occur during muscle contraction against fixed resistance

Essential tremor is primarily characterized by action tremor (4-12 Hz) involving arms and hands, and may include postural tremor components. It should be distinguished from other tremor types such as parkinsonian tremor, dystonic tremor, enhanced physiological tremor, and drug-induced tremor.

Pharmacological Treatment Algorithm

1. First-line medications:

   • Propranolol: 40 mg twice daily (maximum 240 mg daily)
   • Primidone: Start low and titrate slowly
   • Topiramate: Effective alternative

2. If first-line medications fail or cause side effects:

   • Alternative beta-blockers: Metoprolol, atenolol, or nadolol (for patients with respiratory concerns or contraindications to propranolol)
   • Gabapentin: 300-2400 mg daily (divided into three doses) - particularly effective for patients with comorbid neuropathic pain
   • Benzodiazepines (such as clonazepam): Can provide benefit but use with caution due to dependence risk

3. For specific tremor types:

   • Head or voice tremor: Consider botulinum toxin injections
   • Functional tremor: Consider psychotherapy and antidepressants
   • Orthostatic tremor: Gabapentin and clonazepam are often recommended 2

Surgical Options for Medication-Refractory Tremor

When tremor causes significant functional disability despite optimal medical therapy, surgical options should be considered:

1. MR-guided focused ultrasound (MRgFUS) thalamotomy:

   • Non-invasive option with lower complication rate (4.4%)
   • Currently indicated only for unilateral treatment
   • Contraindicated in patients with MRI contraindications or skull density ratio <0.40

2. Deep brain stimulation (DBS):

   • Provides adequate tremor control in approximately 90% of patients 1, 3
   • Preferred for bilateral procedures due to fewer complications than bilateral ablative procedures
   • Higher complication rate (21.1%) than MRgFUS

3. Radiofrequency thalamotomy:

   • Effective but has a higher complication rate (11.8%) than MRgFUS
   • Generally reserved for when DBS or MRgFUS are not possible

Special Considerations for Specific Tremor Types

• Dystonic tremor: May respond to anticholinergics 2
• Multiple sclerosis tremor: Responds poorly to drug treatment; severe cases may benefit from thalamic DBS 2
• Parkinsonian tremor: Combination therapy with carbidopa and levodopa remains the first-line approach 4
• Functional tremor: Benefits from antidepressants and multidisciplinary treatment 2

Treatment Approach Based on Tremor Severity

• Mild tremor or situational tremor: Consider as-needed propranolol or benzodiazepines during periods when tremor causes functional disability 3
• Moderate to severe tremor: Start with either propranolol or primidone; if inadequate control, use in combination 1, 3
• Severe, medication-refractory tremor: Evaluate for surgical candidacy 1

Common Pitfalls to Avoid

• Misdiagnosing dystonic tremor as essential tremor
• Overlooking drug-induced causes of tremor
• Failing to recognize psychogenic tremor
• Inadequate dosing of medications
• Not considering surgical options for severe, medication-refractory tremors

Current treatments can improve tremor in many patients, but it's important to note that there is no cure for essential tremor nor are there medications that can slow its progression. Treatment should be initiated when tremor causes functional disability that impacts quality of life.