What are the recommended medications for treating essential tremors?

Medications for Essential Tremor

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

First-Line Medications

Beta-Blockers

• Propranolol: 40 mg twice daily, up to maximum 240 mg daily 1, 2

  • Most extensively studied and FDA-approved for essential tremor
  • Contraindicated in patients with asthma, COPD, heart block, or bradycardia
  • May mask symptoms of hypoglycemia in diabetic patients 1

• Alternative beta-blockers (if propranolol causes adverse effects):

  • Metoprolol: Less effective but option for patients with respiratory concerns 1
  • Atenolol: Fewer central nervous system effects 1
  • Nadolol: Alternative option with fewer CNS side effects 1

Anticonvulsants

• Primidone: Start at low dose (12.5-25 mg) at bedtime, gradually increase to 50-250 mg daily

  • Can be used alone or in combination with propranolol for enhanced effect 2
  • Common side effects: sedation, nausea, dizziness, confusion (especially in elderly)

• Topiramate: Start at 25 mg daily, gradually increase to 100-400 mg daily

  • Effective for tremor control 1, 3
  • Side effects include cognitive slowing, weight loss, paresthesias

Second-Line Medications

• Gabapentin: 300-2400 mg daily, divided into three doses 1, 4

  • Particularly effective for patients with comorbid neuropathic pain 1
  • Randomized controlled trial showed comparable efficacy to propranolol 4
  • Generally well-tolerated with fewer side effects than primidone

• Benzodiazepines (e.g., clonazepam)

  • Can be used for intermittent treatment during periods of stress/anxiety 2
  • Not recommended for long-term use due to risk of dependence and tolerance

Treatment Algorithm

1. Initial Assessment:

   • Determine if tremor causes functional disability requiring treatment 1, 2
   • Rule out secondary causes (thyroid dysfunction, metabolic disorders, medication-induced tremor) 1

2. Treatment Initiation:

   • For mild, intermittent tremor: Propranolol as needed during stressful situations 2
   • For persistent, disabling tremor: Start with either propranolol or primidone 2

3. Inadequate Response:

   • If single agent provides partial benefit: Add second agent (propranolol + primidone) 2
   • If no benefit from first-line agents: Try gabapentin or topiramate 1, 3

4. Refractory Tremor:

   • Consider surgical options for medication-refractory cases:
     • Deep brain stimulation (DBS) of thalamus: 90% effectiveness, preferred for bilateral tremor 1, 5
     • MR-guided focused ultrasound thalamotomy: For unilateral tremor 1, 5

Special Considerations

• Head or Voice Tremor: Botulinum toxin injections may provide relief 2, 5

  • Less commonly used for hand tremor due to risk of weakness 2

• Elderly Patients:

  • Start medications at lower doses and titrate more slowly
  • Monitor for cognitive side effects with primidone and topiramate
  • Consider gabapentin as it may be better tolerated 4

Common Pitfalls

• Failure to recognize that medications typically reduce tremor by only about 50%, not eliminate it completely 2, 6
• Inadequate dose titration before declaring treatment failure
• Not considering combination therapy when single agents provide insufficient benefit
• Overlooking non-pharmacological approaches (weighted utensils, occupational therapy) as adjuncts to medication
• Continuing ineffective medications rather than moving to alternative options or surgical interventions for severe cases

Remember that while these medications can significantly improve quality of life by reducing tremor severity, they do not alter the natural progression of essential tremor 2.