What is the medication treatment for benign essential tremor?

Medication Treatment for Benign 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:
  • Dosage: 40 mg twice daily, maximum 240 mg daily 1
  • Most extensively studied beta-blocker for essential tremor
  • Recommended as first-line treatment by the American Heart Association 1
  • Provides improvement in all patients with essential tremor, particularly in upper extremities 2
  • Works by decreasing corticospinal excitability and increasing short afferent inhibition 3

Anticonvulsants

• Primidone:

  • First-line alternative to propranolol 1
  • Exerts therapeutic effects by blocking voltage-gated sodium channels and modulating GABA-A and GABA-B intracortical circuits 3
  • Better response predicted in patients with better cerebellar function 3

• Topiramate:

  • Considered a first-line option alongside propranolol and primidone 1

Second-Line and Alternative Beta-Blockers

If propranolol causes adverse effects, consider:

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

Other Medication Options

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

  • Particularly effective for patients with comorbid neuropathic pain 1
  • Can be considered if first-line treatments are ineffective

• Benzodiazepines (e.g., clonazepam):

  • Can be used when primidone and propranolol don't provide adequate control 4
  • Also useful for situational tremor during periods of stress and anxiety 4

Treatment Algorithm

1. Assess tremor severity and impact on quality of life

   • Initiate treatment only when tremor causes functional disability 1, 4

2. For persistent disabling tremor:

   • Start with either propranolol or primidone as monotherapy 1, 4

3. If inadequate response to monotherapy:

   • Combine propranolol and primidone 4

4. If combination therapy fails or is not tolerated:

   • Try gabapentin or topiramate 1, 4
   • Consider benzodiazepines (e.g., clonazepam) 4

5. For refractory cases with significant disability despite optimal medical therapy:

   • Consider surgical options:
     • MR-guided focused ultrasound thalamotomy (for unilateral treatment)
     • Deep brain stimulation (DBS) of the thalamus (preferred for bilateral procedures)
     • Radiofrequency thalamotomy 1

Special Considerations

• For head or voice tremor: Consider botulinum toxin injections 4
• For situational tremor: Propranolol or benzodiazepines can be used only during periods when tremor causes functional disability 4
• Important caveat: Currently available medications improve tremor in only approximately 50% of patients 1, 4
• Treatment limitations: No medications can cure essential tremor or slow its progression 4

Medications with Questionable Efficacy

Some medications have been tried but have limited evidence supporting their use:

• Carbonic anhydrase inhibitors (e.g., methazolamide)
• Phenobarbital
• Calcium channel antagonists (e.g., nimodipine)
• Isoniazid
• Clonidine
• Clozapine
• Mirtazapine 4

Remember that treatment should be initiated only when tremor causes functional disability, as essential tremor, while progressive, does not shorten life expectancy 1, 4.