What are the suggested treatments for essential tremor (ET)?

From the Guidelines

For essential tremor, I strongly recommend starting with propranolol, a beta-blocker that has been used to treat ET for over 40 years, as it is a well-established and effective treatment option. According to a recent study published in 2022 in the journal Hypertension 1, propranolol has been used to treat essential tremor for more than 40 years, and other beta-blockers like metoprolol may also be effective depending on the case.

Treatment Options

• Propranolol is a first-line medication option for essential tremor, with a dosage range of 20-320 mg daily.
• Other beta-blockers, such as metoprolol, may also be effective, depending on the individual case, as noted in the study 1.
• Lifestyle modifications, such as avoiding caffeine, getting adequate sleep, and reducing stress, can also help alleviate symptoms.

Additional Considerations

• If propranolol is ineffective, other medication options like primidone, topiramate, gabapentin, or benzodiazepines like clonazepam may be considered.
• For severe cases unresponsive to medication, deep brain stimulation or focused ultrasound thalamotomy may be viable options.
• Physical therapy and occupational therapy can help develop coping strategies, and weighted utensils or wrist weights may improve function.

Dosage and Follow-up

• Start with low medication doses and gradually increase to minimize side effects.
• Regular follow-up is crucial to assess treatment effectiveness and adjust as needed, ensuring the best possible outcome for patients with essential tremor.

From the Research

Suggested Treatments for Essential Tremor (ET)

The following are suggested treatments for essential tremor (ET) based on available evidence:

• Medications:
  • Propranolol and primidone are considered the mainstays of pharmacologic therapy for ET 2, 3, 4, 5, 6
  • Other beta-adrenoceptor antagonists, such as metoprolol or atenolol, may be used if propranolol is not effective 2, 5
  • Topiramate, gabapentin, and benzodiazepines may also be useful in reducing tremor 2, 4, 5, 6
• Surgical Options:
  • Thalamotomy and deep brain stimulation of the thalamus may be considered for patients with disabling tremor that does not respond to medication 2, 3, 4
  • Unilateral Ventralis intermedius thalamic DBS, radiofrequency thalamotomy, and MRI-guided focused ultrasound thalamotomy may be useful for limb tremor in ET 4
• Other Treatments:
  • Botulinum toxin injections into the muscles may provide relief from head or voice tremor 2, 4, 6
  • Local injections with botulinum toxin A may be useful for patients with refractory ET, especially those with head tremor 6

Treatment Recommendations

Treatment for ET is recommended if the tremor causes functional disability 2. The choice of treatment depends on the severity of the tremor, the presence of other medical conditions, and the patient's preferences. According to evidence-based guidelines, propranolol, primidone, and topiramate (>200 mg/day) are the pharmacological interventions that have robustly supported efficacy 4.

Future Treatment Options

Several new drugs, including 1-octanol, sodium oxybate, dimethoxymethyl-diphenyl-barbituric acid (T-2000), and carisbamate, are currently under investigation for the treatment of ET 5. Additionally, T calcium channel blockers, modulators of GABAA receptors (GABAARs), GABAB receptors (GABABRs), and glutamatergic neurotransmission, and drugs that decrease the expression of LINGO-1 may be interesting options for the future 6.