What are the treatment options for tremors related to myelitis?

Treatment Options for Tremors Related to Myelitis

For tremors related to myelitis, propranolol or primidone should be used as first-line pharmacological treatment, as these medications are effective in up to 70% of patients with tremor. 1

First-Line Pharmacological Options

• Propranolol is the most established medication for tremor treatment, having been used for over 40 years with demonstrated efficacy 1, 2
• Primidone is another effective first-line option that can be considered 1, 3
• These medications should be initiated when tremor symptoms interfere with function or quality of life 1, 3

Second-Line Pharmacological Options

• If first-line treatments are ineffective or poorly tolerated, consider:
  • Other beta-blockers such as metoprolol or atenolol 2
  • Topiramate, which has shown efficacy in moderate to severe tremor (29% improvement vs. 16% with placebo) 4
  • Gabapentin as an alternative second-line agent 2, 3
  • Carbamazepine, though generally less effective than first-line therapies 1
  • Benzodiazepines, particularly for patients with associated anxiety 2

Special Considerations for Medication Selection

• Beta-blockers like propranolol should be avoided in patients with:
  • Chronic obstructive pulmonary disease
  • Bradycardia
  • Congestive heart failure 1
• Beta-blockers may cause adverse effects including:
  • Lethargy and depression
  • Dizziness and hypotension
  • Exercise intolerance and sleep disorders 1
• In elderly patients, excessive heart rate reduction with beta-blockers may lead to serious adverse events 1
• Consider high-dose thiamine as an alternative treatment, which has shown promising results in case reports with minimal side effects 5

Treatment Algorithm

1. Initial assessment:

   • Evaluate tremor severity and impact on quality of life 1, 3
   • Identify any contraindications to first-line medications 1

2. First-line treatment:

   • Start with propranolol (typical dose range: 40-320 mg/day) or primidone 1, 2
   • Trial for at least 4 weeks to assess efficacy 3

3. If inadequate response or intolerable side effects:

   • Switch to alternative first-line agent or add second-line medication 1, 3
   • Consider topiramate (target dose 400 mg/day), which can be effective at doses as low as 100 mg/day 4

4. For refractory tremor:

   • Consider surgical options if medications fail due to lack of efficacy, side effects, or contraindications 1, 3
   • Surgical options include:
     • Deep brain stimulation (DBS) 1, 3
     • Magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy 6, 1
     • Radiofrequency thalamotomy 6, 1

Surgical Considerations

• MRgFUS thalamotomy has shown sustained tremor improvement of 56% at 4 years 1
• MRgFUS thalamotomy has a lower complication rate (4.4%) compared to radiofrequency thalamotomy (11.8%) and DBS (21.1%) 6, 1
• Contraindications for MRgFUS include:
  • Inability to undergo MRI
  • Skull density ratio <0.40
  • Previous thalamotomy on the contralateral side 6, 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
• If first-line agents fail, consider switching to or adding second-line medications before considering surgical options 1, 3