What medications are used to treat tremor, specifically essential tremor and tremors associated with Parkinson's disease?

Medications for Tremor Treatment

For essential tremor, first-line treatment is propranolol or primidone, which are effective in up to 70% of patients, while Parkinson's disease tremor is primarily treated with levodopa-based medications. 1

Essential Tremor Treatment

First-Line Medications

• Propranolol (a non-selective beta-blocker) is the most established medication for essential tremor, having been used for over 40 years with demonstrated efficacy 1
• Primidone is another first-line option, though not detailed in the provided evidence 1
• These medications are only initiated when tremor symptoms interfere with function or quality of life 1

Second-Line Medications

• Gabapentin has shown efficacy comparable to propranolol in some studies, making it a viable alternative 2
• Carbamazepine may be used, though it's generally not as effective as first-line therapies 1
• Metoprolol (a selective beta-blocker) has demonstrated similar tremor reduction (47%) compared to propranolol (55%) in controlled studies 3

Dosing Considerations

• Propranolol is typically administered at doses of 40-120 mg three times daily 4, 3
• Long-acting propranolol formulations have shown benefit in 82.5% of patients with no previous treatment 5

Parkinson's Disease Tremor Treatment

Primary Medications

• Levodopa (often combined with carbidopa) is the mainstay of pharmacologic therapy for Parkinson's disease tremor 6, 7, 8
• Carbidopa-levodopa is available in various formulations including standard tablets and orally disintegrating tablets 6, 7

Adjunctive Medications

• Dopamine agonists can be used as monotherapy or in combination with levodopa 8
• Other agents that may be beneficial include amantadine, anticholinergics, and selegiline 8

Treatment Selection Considerations

Contraindications and Cautions

• Beta-blockers (like propranolol) should be avoided in patients with:
  • Chronic obstructive pulmonary disease 1
  • Bradycardia 1
  • Congestive heart failure 1
• Beta-blockers may cause adverse effects including:
  • Lethargy and depression 1
  • Dizziness and hypotension 1
  • Exercise intolerance and sleep disorders 1

Special Populations

• In elderly patients, excessive heart rate reduction with beta-blockers may lead to serious adverse events 1
• For patients with both essential tremor and hypertension, beta-blockers may provide dual benefits 1

Surgical Options for Refractory Tremor

• When medications fail due to lack of efficacy, side effects, or contraindications, surgical therapies may be considered 1
• Options include:
  • Deep brain stimulation (DBS) targeting the ventral intermediate nucleus of the thalamus 1
  • Magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy, which has shown sustained tremor improvement of 56% at 4 years 1
  • Radiofrequency thalamotomy 1

Monitoring and Follow-up

• Regular assessment of tremor severity and medication side effects is essential 1
• Dose adjustments may be needed based on clinical response and tolerability 1, 5
• If first-line agents fail, consider switching to or adding second-line medications before considering surgical options 1