Can Ativan Help with Tremors?
Ativan (lorazepam) can provide modest benefit for tremors, particularly when tremor is associated with anxiety or stress, but it is not a first-line treatment for most tremor disorders and should be reserved for specific situations where anxiety exacerbates tremor or when first-line agents have failed.
Clinical Context and Evidence
When Benzodiazepines May Help Tremors
Benzodiazepines, including lorazepam, can be effective for tremor control in some patients, particularly those with associated anxiety 1, 2.
In patients with generalized anxiety disorder who have tremor, treatment with benzodiazepines (such as alprazolam, which is similar to lorazepam) has shown favorable effects on tremor comparable to propranolol 3.
If tremor is disabling only during periods of stress and anxiety, benzodiazepines can be used during those specific periods when tremor causes functional disability 1.
Limitations and Treatment Hierarchy
Propranolol and primidone remain the first-line treatments for essential tremor, with currently available medications improving tremor in approximately 50% of patients 1, 2.
Benzodiazepines like clonazepam (and by extension lorazepam) are typically considered only after propranolol and primidone have failed to provide adequate tremor control 1.
The tremor in anxiety disorders appears to be an enhanced physiological tremor affecting primarily the upper limbs with postural and kinetic characteristics 3.
Important Safety Considerations
Adverse Effects Specific to Tremor
The FDA label for lorazepam lists tremor itself as a potential adverse effect, along with ataxia, unsteadiness, and extrapyramidal symptoms 4.
Sedation occurs in 15.9% of patients, dizziness in 6.9%, weakness in 4.2%, and unsteadiness in 3.4%, with incidence increasing with age 4.
Risks in Specific Populations
For elderly or debilitated patients, maximum dosing should not exceed 2 mg in 24 hours (0.25-0.5 mg orally), compared to 4 mg maximum for general adults 5.
Regular use of lorazepam can lead to tolerance, addiction, depression, and cognitive impairment 5.
Elderly patients are significantly more sensitive to the sedative effects of benzodiazepines and require careful monitoring and dose adjustment 6.
Withdrawal Considerations
- For older adults discontinuing benzodiazepines, withdraw 25% of the daily dose each week, though more gradual tapering may be necessary for long-term users 6.
Clinical Algorithm for Tremor Management
Step 1: Identify if tremor is primarily stress/anxiety-related or occurs during specific situations versus constant disabling tremor.
Step 2: For constant disabling tremor, initiate treatment with propranolol or primidone as first-line agents 1.
Step 3: If first-line agents fail or are not tolerated, consider combination therapy with propranolol plus primidone 1.
Step 4: Only after failure of first-line options, consider benzodiazepines like lorazepam for tremor control 1, 2.
Step 5: For situational tremor related to anxiety/stress, lorazepam can be used as-needed during those specific periods 1.
Alternative Approaches to Consider
Non-pharmacological approaches such as cognitive-behavioral therapy, supportive psychotherapy, and problem-solving therapy should be considered as alternatives or adjuncts 6.
For older adults with anxiety-related tremor, alternative pharmacological options may include buspirone or certain antidepressants, which have less risk of cognitive impairment and falls 6.
Other medications with potential benefit include gabapentin or topiramate if propranolol and primidone are inadequate 1.
Common Pitfalls to Avoid
Do not use lorazepam as first-line therapy for essential tremor—this bypasses more effective and safer long-term options 1, 2.
Avoid chronic daily use without attempting alternative treatments, as tolerance and dependence develop with regular benzodiazepine use 5.
Monitor for paradoxical reactions including anxiety, excitation, and agitation, which occur in approximately 10% of patients treated with benzodiazepines 5, 4.
Be aware that lorazepam itself can cause tremor as an adverse effect, potentially worsening the clinical picture 4.