What are the treatment options for managing head tremors?

Management of Head Tremors

Propranolol and primidone are the first-line pharmacological treatments for head tremors, with treatment initiated only when tremor interferes with function or quality of life. 1

Types of Head Tremors

• Head tremors typically present as part of essential tremor syndrome, which is a progressive neurological condition with a prevalence between 0.3% and 5.55% in the US 2
• Isolated head tremor is more likely to be dystonic rather than essential tremor 3
• Head tremors can significantly interfere with quality of life, functional activities, mood, and socialization 4

First-Line Pharmacological Treatments

• Beta-blockers:

  • Propranolol is the most established medication for essential tremor, with dosage range of 80-240 mg/day 1
  • Propranolol has been used for over 40 years with demonstrated efficacy 1
  • Alternative beta-blockers include nadolol (40-320 mg daily), metoprolol (25-100 mg extended release daily or twice daily), and timolol (20-30 mg/day) 1
  • Beta-blockers should be avoided in patients with chronic obstructive pulmonary disease, bradycardia, or congestive heart failure 1
  • Common adverse effects include fatigue, depression, nausea, dizziness, insomnia, cold extremities, and bronchospasm 1

• Primidone:

  • Primidone is another first-line option for essential tremor 1
  • It can be effective in up to 70% of patients 1

Second-Line Pharmacological Options

• Gabapentin has limited evidence for moderate efficacy in tremor management 1
• Carbamazepine may be used as a second-line therapy for essential tremor, though generally not as effective as first-line therapies 1
• Topiramate has shown efficacy in moderate to severe essential tremor with mean percentage improvement of 29% compared to 16% with placebo 5

Botulinum Toxin Injections

• Botulinum toxin injections have shown potential effectiveness for treating head and voice tremors 2
• Botulinum toxin is the treatment of choice in dystonic tremor 3

Non-Pharmacological Approaches

• Rhythm modification techniques can help control tremor, including superimposing alternative rhythms on existing tremor 1
• For unilateral tremor, using the unaffected limb to dictate a new rhythm can help entrain the tremor to stillness 1
• Using gross rather than fine movements can be helpful 1
• Avoid cocontraction or tensing of muscles as this is unlikely to be a helpful long-term strategy 1

Surgical Options for Refractory Tremor

• Consider surgical therapies when medications fail due to lack of efficacy at maximum doses, dose-limiting side effects, medical contraindications, or occupational limitations 1
• Options include:
  • Magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy: Shows sustained tremor improvement of 56% at 4 years 1
  • Deep brain stimulation (DBS): Established treatment for medication-refractory tremor 1
  • Radiofrequency thalamotomy: Another surgical option for refractory tremor 1
• MRgFUS thalamotomy has a lower complication rate (4.4%) compared to radiofrequency thalamotomy (11.8%) and DBS (21.1%) 1
• MRgFUS thalamotomy is contraindicated bilaterally or contralateral to a previous thalamotomy, in patients with skull density ratio <0.40, or in those unable to undergo MRI 1

Treatment Algorithm

1. Initial assessment:

   • Determine if tremor is essential tremor or dystonic tremor 3
   • Assess impact on function and quality of life 1

2. First-line treatment:

   • Start with propranolol (80-240 mg/day) or primidone if tremor interferes with function or quality of life 1
   • For patients with both tremor and hypertension, beta-blockers may provide dual benefits 1

3. If first-line treatment fails:

   • Try alternative beta-blockers or add second-line medications 1
   • Consider botulinum toxin injections, especially for dystonic head tremor 3

4. For refractory cases:

   • Consider surgical options based on patient characteristics 1
   • For unilateral tremor or patients with medical comorbidities, consider MRgFUS thalamotomy 1
   • For bilateral tremor, consider DBS 1

Important Considerations and Pitfalls

• Regular assessment of tremor severity and medication side effects is essential 1
• Dose adjustments may be needed based on clinical response and tolerability 1
• Avoid prescribing aids and equipment for functional tremor in the acute phase 1
• If aids are necessary for safety, consider them short-term solutions with a plan to progress toward independence 1