What are the treatment options for tremors?

Treatment Options for Tremors

The most effective treatment for tremors depends on the specific tremor type, with propranolol and primidone being first-line pharmacological options for essential tremor, while levodopa/carbidopa is the mainstay for parkinsonian tremor, and surgical interventions like MRgFUS thalamotomy or DBS should be considered for medication-refractory cases. 1, 2

Tremor Classification and Initial Approach

• Tremors are classified as rest tremors (present when body part is at rest, typical of Parkinson's disease) or action tremors (postural or kinetic, seen in essential tremor) 3
• Essential tremor is characterized by bilateral action tremor of arms and hands, significantly affecting quality of life and daily activities 1
• Enhanced physiologic tremor can be triggered by anxiety, stress, strenuous exercise, or caffeine consumption 4
• Intentional tremor is characterized by coarse, irregular tremor that worsens during goal-directed movements, often associated with cerebellar pathology 1

Pharmacological Treatment Options

For Essential Tremor

• Propranolol (80-240 mg/day) and primidone are recommended as first-line treatments by the American Academy of Neurology, with efficacy in up to 70% of patients 2
• Beta-blockers should be avoided in patients with chronic obstructive pulmonary disease, bradycardia, or congestive heart failure 2
• For patients with both essential tremor and hypertension, beta-blockers may provide dual benefits 2
• Second-line options include gabapentin, though it has limited evidence for moderate efficacy 2

For Parkinsonian Tremor

• Levodopa/carbidopa remains the first-line approach for parkinsonian tremor 5, 6
• Levodopa works by crossing the blood-brain barrier and converting to dopamine in the brain, addressing the dopamine depletion in the corpus striatum 5
• Extended-release formulations of levodopa/carbidopa may help patients with motor fluctuations by providing steadier plasma levels 5
• Other agents that may be used in combination with levodopa include dopamine agonists, amantadine, and anticholinergics 7

For Other Tremor Types

• Clonazepam may be effective for orthostatic tremor 8
• Isoniazid may help control cerebellar tremor associated with multiple sclerosis 8
• For enhanced physiologic tremor, lifestyle modifications like reducing caffeine and implementing stress reduction techniques can be helpful 4

Non-Pharmacological Approaches

• Rhythm modification techniques can help control tremor, including superimposing alternative rhythms on existing tremor and gradually slowing movement to complete rest 9
• For unilateral tremor, using the unaffected limb to dictate a new rhythm can help entrain the tremor to stillness 9
• Using gross rather than fine movements can be helpful, especially for activities like handwriting 9
• Avoiding cocontraction or tensing of muscles as this is unlikely to be a helpful long-term strategy 9

Surgical Options for Refractory Tremor

• Surgical therapies should be considered when medical therapies fail due to lack of efficacy at maximum doses 9
• Magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy shows sustained tremor improvement of 56% at 4 years 2
• MRgFUS thalamotomy has a lower complication rate (4.4%) compared to radiofrequency thalamotomy (11.8%) and deep brain stimulation (DBS) (21.1%) 9, 2
• MRgFUS is contraindicated in patients who cannot undergo MRI, have skull density ratio <0.40, or need bilateral treatment 9
• Deep brain stimulation (DBS) offers the advantage of being reversible and effective for other motor symptoms 6

Important Considerations and Pitfalls

• Medication treatment should only be initiated when tremor interferes with function or quality of life 1, 2
• Avoid prescribing aids and equipment for functional tremor in the acute phase, as they may interrupt normal automatic movement patterns 9
• If aids are necessary for safety, they should be considered short-term solutions with a plan to progress toward independence 9
• Regular assessment of tremor severity and medication side effects is essential for optimal management 2
• For elderly patients, excessive heart rate reduction with beta-blockers may lead to serious adverse events 2