What is the treatment for a mouth tremor?

Treatment of Mouth Tremor

The treatment of mouth tremor should focus on using rhythmic techniques to superimpose alternative voluntary movements on top of the existing tremor, gradually slowing all movement to complete rest, while also incorporating muscle relaxation strategies to prevent cocontraction. 1

Diagnosis and Classification

Before initiating treatment, it's important to determine the type of tremor affecting the mouth:

• Functional tremor (4-8 Hz): Occurs when maintaining position against gravity
• Kinetic tremor: Occurs during voluntary movement
• Rest tremor (4-6 Hz): Occurs when body part is relaxed and supported

Laboratory testing should be considered to rule out secondary causes, including:

• Thyroid function tests
• Liver function tests
• Basic metabolic panel
• HbA1c
• Copper studies (if Wilson's disease is suspected) 2

First-Line Treatment Approaches

Non-Pharmacological Interventions

For functional mouth tremor, implement the following strategies:

1. Rhythm-based techniques:

   • Superimpose alternative, voluntary rhythms on top of the existing tremor
   • Gradually slow all movement to complete rest
   • Use the unaffected side to dictate a new rhythm
   • Introduce music to establish a rhythm to follow 1

2. Muscle relaxation strategies:

   • Assist the person to relax the muscles to prevent cocontraction
   • Begin with controlling tremor at rest before moving to activity
   • Avoid cocontraction or tensing of muscles as a suppression method 1

3. Distraction techniques:

   • Use gross rather than fine movements
   • Implement sensory grounding (focusing on environmental details)
   • Practice diaphragmatic breathing or progressive muscle relaxation 1

Pharmacological Treatment

If non-pharmacological approaches are insufficient, medication options include:

1. Beta-blockers:

   • Propranolol: 40 mg twice daily (maximum 240 mg daily) - first-line treatment
   • Alternative beta-blockers for those with respiratory concerns:
     • Metoprolol (fewer respiratory effects)
     • Atenolol (fewer central nervous system effects)
     • Nadolol (alternative for propranolol contraindications) 2, 3

2. Other medications:

   • Primidone: Can be used alone or in combination with propranolol
   • Topiramate: 300-2400 mg daily in divided doses
   • Gabapentin: Effective especially with comorbid neuropathic pain
   • Benzodiazepines (e.g., clonazepam): For additional control when first-line treatments fail 2, 3

Treatment Algorithm

1. Start with non-pharmacological approaches (rhythm techniques, relaxation strategies)
2. If insufficient response, add pharmacological treatment:
   • Begin with propranolol (if no contraindications)
   • If propranolol is contraindicated or causes adverse effects, try alternative beta-blockers
   • For inadequate response, add primidone or try combination therapy
3. For refractory cases, consider botulinum toxin injections 2, 4

Special Considerations

• Beta-blockers can cause bradycardia, bronchospasm, sleep disturbances, and cold extremities
• Beta-blockers may mask symptoms of hypoglycemia (caution in diabetic patients)
• Medications typically improve tremor in approximately 50% of patients 2, 3
• For severe, medication-refractory tremor affecting quality of life, surgical options like deep brain stimulation may be considered, providing tremor control in approximately 90% of patients 3

Monitoring and Follow-up

• Assess tremor severity and impact on quality of life regularly
• Adjust treatment based on response and side effects
• Continue treatment as long as tremor causes functional disability 2