What is the initial treatment for orthostatic tremor?

Treatment of Orthostatic Tremor

Gabapentin is the first-line treatment for orthostatic tremor, with multiple studies showing 50-75% symptom reduction, improved postural stability, and enhanced quality of life. 1, 2, 3, 4

Understanding Orthostatic Tremor

Orthostatic tremor (OT) is a rare movement disorder characterized by:

• High-frequency tremor (13-18 Hz) in the legs that occurs when standing 5
• Rapid improvement of symptoms when sitting or walking 5
• Typically begins in the sixth decade of life 5
• Strong urge to sit down or move when standing still 5

Diagnostic Confirmation

• Polygraphic recording showing fast, synchronous tremor of the legs (13-18 Hz) is mandatory for diagnosis 5
• Many patients also have tremor of the face, hands, or trunk, often at lower frequencies 5

Treatment Algorithm

First-line Treatment:

• Gabapentin (300-2,400 mg/day)
  • Start at 300 mg three times daily and titrate as needed 4
  • Multiple controlled studies show 50-75% symptom reduction 2, 3
  • Reduces tremor amplitude by up to 70% 4
  • Improves postural stability and reduces sway area to 71% of placebo state 2
  • Benefits maintained long-term (mean follow-up 19 months) 2
  • Side effects are generally mild, transient, and dose-related 1

Alternative/Second-line Treatments:

• Clonazepam

  • Widely used but often provides only transitory response 3
  • Consider when gabapentin is contraindicated or ineffective 5

• Dopaminergic medications

  • May be helpful in some patients 5
  • Particularly consider in patients with concurrent Parkinson's disease 5

Dosing Considerations

• Initial gabapentin dose: 300 mg three times daily 4
• Titrate dose based on response and tolerability
• Effective dose range: 300-2,700 mg/day (mean effective dose: 1,030 mg/day) 1, 2
• Lower starting doses and more gradual titration may reduce adverse effects, especially in older individuals 6

Monitoring and Follow-up

• Assess subjective symptom improvement (patient-reported severity)
• Monitor for side effects, which are typically mild and transient 1
• Consider quantitative measures when available (posturography, tremor amplitude) 2, 4
• Evaluate quality of life improvements 2, 4

Special Considerations

• Response to treatment is often disappointing with many medications, making gabapentin's documented efficacy particularly valuable 5
• Some patients may require combination therapy with clonazepam or dopaminergic agents if gabapentin alone is insufficient 5
• Orthostatic tremor may sometimes be associated with Parkinson's disease, suggesting a dopaminergic component in some cases 5

Pitfalls to Avoid

• Don't confuse orthostatic tremor with orthostatic hypotension, which requires different management approaches 6
• Avoid delaying treatment, as orthostatic tremor significantly impacts quality of life 2, 4
• Don't stop at insufficient doses - titrate to effective dose (up to 2,700 mg/day) before concluding treatment failure 1, 2