What medications are used to treat hand tremor, specifically essential tremor?

Medications for Hand Tremor (Essential Tremor)

Propranolol is the first-line medication for essential tremor, with approximately 50% efficacy in reducing tremor severity and improving functional ability. 1

First-Line Medications

Beta-Blockers

• Propranolol: 40 mg twice daily, maximum 240 mg daily 1, 2
  • Most extensively studied and effective beta-blocker for essential tremor
  • Can be used as needed during periods of stress when tremor worsens 2
  • Contraindications: asthma, COPD, bradycardia, heart block
  • Side effects: bradycardia, bronchospasm, sleep disturbances, cold extremities, masking of hypoglycemia symptoms 1

Alternative Beta-Blockers (if propranolol not tolerated)

• Metoprolol: Less effective but option for patients with respiratory concerns 1
• Atenolol: Fewer central nervous system effects 1
• Nadolol: Alternative option for those with propranolol contraindications 1

Other First-Line Options

• Primidone: Start at low doses (12.5-25 mg) and gradually increase to minimize side effects 2, 3
  • Can be used alone or in combination with propranolol for refractory cases 2
  • Acute adverse reactions occur in approximately 32% of patients 4

Second-Line Medications

• Topiramate: Effective in approximately 50% of patients 1, 3

  • Side effects include cognitive slowing, weight loss, paresthesias

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

  • Particularly useful for patients with comorbid neuropathic pain
  • Better tolerated than primidone but possibly less effective

• Benzodiazepines (e.g., clonazepam):

  • Can be used as adjunctive therapy for refractory tremor 2
  • Risk of dependence and cognitive side effects limits long-term use

Treatment Algorithm

1. Initial Assessment:

   • Determine tremor severity and functional impact
   • Rule out secondary causes (thyroid dysfunction, medication-induced tremor)
   • Consider laboratory testing: thyroid function, liver function, basic metabolic panel, HbA1c 1

2. Treatment Decision:

   • For mild tremor or situational tremor: as-needed propranolol
   • For moderate to severe tremor causing functional disability: daily propranolol or primidone

3. If First-Line Treatment Fails:

   • Try alternative beta-blocker if propranolol not tolerated
   • Consider combination therapy with propranolol and primidone 2
   • Add or switch to topiramate or gabapentin

4. For Refractory Cases:

   • Consider botulinum toxin injections (particularly effective for head tremor) 2, 5
   • Evaluate for surgical candidacy (deep brain stimulation or MR-guided focused ultrasound) 1, 3

Important Considerations

• Treatment should be initiated when tremor causes functional disability 2
• Currently available medications improve tremor in only about 50% of patients 1, 2
• No medication can cure essential tremor or slow its progression 2
• Surgical options (deep brain stimulation or focused ultrasound thalamotomy) provide adequate tremor control in approximately 90% of patients with medication-refractory tremor 1, 2
• For bilateral tremor requiring surgical intervention, deep brain stimulation is preferred over bilateral ablative procedures 1

Common Pitfalls

• Failing to start primidone at a low dose, which can lead to intolerable side effects
• Not considering combination therapy for refractory cases
• Overlooking secondary causes of tremor (thyroid disease, medication effects)
• Delaying surgical referral for patients with severe, medication-refractory tremor