What are the treatment options for essential tremor?

Treatment Options for Essential Tremor

Propranolol and primidone are the first-line medications for essential tremor, and should be initiated when tremor interferes with function or quality of life. 1

First-Line Pharmacological Treatments

• Propranolol is the most established medication for essential tremor with demonstrated efficacy over 40 years of use 1
• Primidone is equally effective as a first-line option for essential tremor 1
• These first-line medications can improve tremor in approximately 50% of patients 2
• Treatment should only be initiated when tremor causes functional disability 1, 2
• For situational tremor that worsens with stress or anxiety, propranolol can be used as needed during those periods 2

Second-Line Pharmacological Options

• If either propranolol or primidone alone doesn't provide adequate control, they can be used in combination 2
• Alternative beta-blockers (atenolol or metoprolol) may be tried if propranolol causes adverse effects 2
• Topiramate can be considered as an alternative second-line agent 3
• Gabapentin has shown efficacy comparable to propranolol in some studies 4
• Benzodiazepines (such as clonazepam) may provide additional benefit when first-line treatments are inadequate 2

Medication Considerations and Contraindications

• Beta-blockers 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
• For patients with both essential tremor and hypertension, beta-blockers may provide dual benefits 1

Surgical Options for Medication-Refractory Tremor

• Surgical therapies should be considered when medications fail due to:

  • Lack of efficacy at maximum doses 5
  • Dose-limiting side effects 5
  • Medical contraindications 5
  • Occupational limitations 5

• Deep brain stimulation (DBS) of the thalamus:

  • Provides adequate tremor control in approximately 90% of patients 2
  • Has fewer complications compared to ablative procedures 2
  • Is the procedure of choice for bilateral procedures 2

• Magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy:

  • Shows sustained tremor improvement of 56% at 4 years 1
  • Has a lower complication rate (4.4%) compared to radiofrequency thalamotomy (11.8%) and DBS (21.1%) 5
  • Contraindicated bilaterally or contralateral to a previous thalamotomy 5
  • Requires a skull density ratio ≥0.40 5
  • Cannot be used in patients unable to undergo MRI 5

• Radiofrequency thalamotomy is another option but less commonly used 1

Treatment Algorithm

1. Start with propranolol or primidone when tremor causes functional disability 1, 2
2. If inadequate response to one first-line agent, try the other or use them in combination 2
3. For persistent disability, add or switch to second-line agents (topiramate, gabapentin, benzodiazepines) 2, 3
4. For medically refractory tremor causing significant disability, consider surgical options:
   • DBS for bilateral tremor or younger patients 2
   • MRgFUS for unilateral tremor or patients with medical comorbidities 1, 5

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
• If tremor progresses despite optimal medical therapy, reevaluate for surgical candidacy 1, 5