What are the treatment options for tremors?

Treatment for Tremors

For essential tremor interfering with function or quality of life, start with propranolol 80-240 mg/day or primidone as first-line therapy, as both are effective in up to 70% of patients. 1, 2

Initial Assessment and Treatment Initiation

Before starting medication, determine if the tremor actually interferes with daily function or quality of life—treatment is only indicated when tremor causes functional impairment, not merely for tremor presence alone. 1, 2

Key factors to assess:

• Interference with writing, eating, drinking, and activities of daily living 2
• Exacerbating factors including anxiety, caffeine, strenuous exercise, or fatigue (suggests enhanced physiologic tremor) 2
• Complete medication review to identify tremor-inducing drugs: antiparkinsonians, lithium, sympathomimetics 2

First-Line Pharmacological Treatment

Propranolol (Preferred Initial Agent)

• Dosage: 80-240 mg/day 1, 2, 3
• Most established medication with over 40 years of demonstrated efficacy 1
• Provides dual benefit in patients with both essential tremor and hypertension 1

Absolute contraindications to propranolol:

• Chronic obstructive pulmonary disease 1, 2, 3
• Bradycardia 1, 2, 3
• Congestive heart failure 1, 2, 3

Common adverse effects:

• Fatigue and depression 1, 3
• Dizziness and hypotension 1, 3
• Exercise intolerance and sleep disorders 1
• Cold extremities and bronchospasm 1
• Elderly patients risk serious adverse events from excessive heart rate reduction 1, 3

Primidone (Alternative First-Line)

• Equally effective as propranolol with comparable 70% response rate 2
• Critical timing consideration: Clinical benefits may not appear for 2-3 months, so an adequate trial period is essential before declaring treatment failure 1, 2
• Therapeutic benefit can occur even when derived phenobarbital levels remain subtherapeutic, confirming primidone itself has anti-tremor properties 1

Adverse effects:

• Behavioral disturbances, irritability, and sleep disturbances (particularly at higher doses) 1
• Teratogenic risks (neural tube defects)—counsel women of childbearing age 1

Alternative Beta-Blockers (If Propranolol Not Tolerated)

• Nadolol: 40-320 mg daily 1
• Metoprolol: 25-100 mg extended release daily or twice daily 1
• Timolol: 20-30 mg/day 1
• Atenolol: Limited evidence for moderate effect 1

Second-Line Pharmacological Options

If first-line agents fail, consider switching to or adding second-line medications before considering surgical options. 1

• Carbamazepine: Second-line therapy, though generally not as effective as first-line therapies 1
• Gabapentin: Limited evidence for moderate efficacy 1, 3
• Topiramate: Can be considered for moderate tremor severity 4

Regular monitoring required:

• Assessment of tremor severity and medication side effects 1
• Dose adjustments based on clinical response and tolerability 1

Non-Pharmacological Interventions

Rhythm Modification Techniques

• Superimpose alternative voluntary rhythms on existing tremor and gradually slow movement to complete rest 1, 2, 3
• For unilateral tremor, use the unaffected limb to dictate a new rhythm to entrain the tremor to stillness 1
• Use gross rather than fine movements, especially for activities like handwriting 1, 3
• Avoid cocontraction or tensing of muscles—this is not a helpful long-term strategy 1

Lifestyle Modifications for Enhanced Physiologic Tremor

• Avoid strenuous exercise before precision tasks 3
• Reduce caffeine consumption 3
• Implement stress reduction techniques 3

Equipment Considerations—Critical Pitfall

Avoid prescribing aids and adaptive equipment in the acute phase, as they may interrupt normal automatic movement patterns and prevent recovery by reinforcing maladaptive patterns. 1, 2 If aids are necessary for safety, consider them short-term solutions with a plan to progress toward independence. 1

Surgical Interventions for Medication-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, 4

Treatment Algorithm for Surgical Candidates

For unilateral tremor or patients with medical comorbidities:

• Magnetic Resonance-Guided Focused Ultrasound (MRgFUS) Thalamotomy is preferred 1, 2, 3
• Sustained tremor improvement of 56% at 4 years 1, 2, 3
• Lowest complication rate: 4.4% (compared to radiofrequency thalamotomy 11.8% and DBS 21.1%) 1, 2, 3
• Early adverse effects: gait disturbance (36%) and paresthesias (38%), decreasing to 9% and 14% respectively by 1 year 1
• Serious adverse events rare (1.6%), with most adverse events mild or moderate (98.4%) and more than 50% resolving by 1 year 1

MRgFUS contraindications:

• Cannot undergo MRI 1, 2
• Skull density ratio <0.40 1, 2
• Bilateral treatment needed 1, 2
• Contralateral to a previous thalamotomy 1, 2

For bilateral tremor involvement or MRgFUS contraindications:

• Deep Brain Stimulation (DBS) of the ventral intermediate nucleus (VIM) of the thalamus 1, 2, 3
• Preferred for relatively young patients as it offers adjustable, reversible tremor control that can be optimized over time 1
• Complication rate: 21.1% 1, 2, 3
• Requires inpatient admission for careful post-operative monitoring 1
• Awake procedure allows intraoperative testing to confirm optimal electrode placement and immediate tremor control 1

Eligibility criteria for DBS:

• No dementia or severe depression 1
• Sufficient residual motor function to expect improvement following surgery 1
• No cerebral atrophy or focal lesions of the basal ganglia on MRI 1
• Failed first-line medication therapy 1
• Tremor significantly affecting activities of daily living 1

Radiofrequency thalamotomy:

• Available but carries higher complication risks (11.8%) than MRgFUS 1, 2
• Only rarely performed if DBS or focused ultrasound not possible 4

Common Pitfalls to Avoid

• Stopping primidone before 2-3 months: Inadequate trial may miss therapeutic benefit 2
• Treating based on tremor presence alone: Treatment should only be initiated when tremor interferes with function or quality of life 1, 2
• Premature equipment provision: Prevents recovery by reinforcing maladaptive movement patterns 2
• Failing to screen for beta-blocker contraindications: Always check for COPD, bradycardia, and CHF before prescribing 1, 2, 3
• Ignoring medication-induced tremor: Complete medication review essential to identify reversible causes 2