What are the treatment options for essential tremors?

Treatment Options for Essential Tremor

First-line treatment for essential tremor consists of propranolol or primidone, which are effective in up to 70% of patients with functionally disabling tremor. 1, 2

Pharmacological Treatment Options

First-Line Medications

• Propranolol (80-240 mg/day) is the most established medication for essential tremor, having been used for over 40 years with demonstrated efficacy 1, 2
• Primidone is an equally effective first-line option for essential tremor 1
• Medications should only be initiated when tremor symptoms interfere with function or quality of life 1

Second-Line Medications

• Other beta-blockers that may be effective for tremor control include:
  • Nadolol (40-320 mg daily) 1
  • Metoprolol (25-100 mg extended release daily or twice daily) 1
  • Atenolol and timolol (20-30 mg/day) 1, 3
• Gabapentin has limited evidence for moderate efficacy in tremor management 1, 3
• Topiramate may be considered as another second-line option 4, 3
• Carbamazepine may be used as a second-line therapy, though generally not as effective as first-line options 1
• Benzodiazepines (such as clonazepam) can provide benefit, particularly in patients with associated anxiety 5, 3

Important Considerations and Contraindications

• Beta-blockers should be avoided in patients with:
  • Chronic obstructive pulmonary disease
  • Bradycardia
  • Congestive heart failure 1, 2
• Common adverse effects of beta-blockers include:
  • Fatigue and depression
  • Dizziness and hypotension
  • Exercise intolerance and sleep disorders 1, 2
• In elderly patients, excessive heart rate reduction with beta-blockers may lead to serious adverse events 1
• For patients with both essential tremor and hypertension, beta-blockers may provide dual benefits 1, 6

Non-Pharmacological Approaches

• Lifestyle modifications that can help manage tremor:
  • Avoiding strenuous exercise before precision tasks
  • Reducing caffeine consumption
  • Implementing stress reduction techniques 2
• Rhythm modification techniques:
  • Superimposing alternative rhythms on existing tremor
  • Gradually slowing movement to complete rest
  • Using gross rather than fine movements for activities like handwriting 1
• For unilateral tremor, using the unaffected limb to dictate a new rhythm can help entrain the tremor to stillness 1

Surgical Options for Refractory Tremor

When medications fail due to lack of efficacy, side effects, or contraindications, surgical options should be considered: 1, 6

• Magnetic Resonance-Guided Focused Ultrasound (MRgFUS) Thalamotomy:

  • Shows sustained tremor improvement of 56% at 4 years
  • Lower complication rate (4.4%) compared to other surgical options
  • Contraindicated in patients who cannot undergo MRI, have skull density ratio <0.40, or need bilateral treatment 1, 6

• Deep Brain Stimulation (DBS):

  • Preferred for bilateral tremor
  • Offers adjustable, reversible tremor control
  • Higher complication rate (21.1%) but suitable for younger patients 1, 6

• Radiofrequency Thalamotomy:

  • Available but carries higher complication risks (11.8%) than MRgFUS 1

Treatment Algorithm

1. Initial Assessment: Determine if tremor interferes with function or quality of life 1

2. First-Line Treatment:

   • Start with propranolol (80-240 mg/day) or primidone 1, 2
   • Expected efficacy: approximately 50-70% of patients will respond 1, 5

3. If Inadequate Response to First-Line Treatment:

   • Try combination of propranolol and primidone 5
   • OR switch to alternative beta-blocker if propranolol causes adverse effects 5, 3
   • OR add/switch to second-line agents (gabapentin, topiramate, benzodiazepines) 5, 4, 3

4. For Refractory Cases:

   • Consider surgical options based on:
     • For unilateral tremor: MRgFUS thalamotomy preferred (lower complication rate) 1, 6
     • For bilateral tremor: DBS preferred 1, 6
     • For patients with contraindications to MRgFUS: Consider DBS or radiofrequency thalamotomy 1

Special Considerations

• Essential tremor can cause greater impairment than Parkinson's disease in activities like writing, eating, drinking, and reading 6
• Current medications can improve tremor in approximately 50% of patients 5
• If tremor is disabling only during periods of stress and anxiety, propranolol and benzodiazepines can be used during those specific periods 5
• For disabling head or voice tremor, botulinum toxin injections into the muscles may provide relief 5, 7