What is the treatment for benign essential tremors (BLE)?

Treatment of Essential Tremor (Lower Extremity)

For lower extremity essential tremor, initiate treatment with propranolol (80-240 mg/day) or primidone as first-line therapy, using the same approach as upper extremity tremor, since these medications are effective in up to 70% of patients regardless of tremor location. 1, 2

First-Line Pharmacologic Treatment

Propranolol is the most established medication, having demonstrated efficacy for over 40 years and should be started at lower doses and titrated up to 80-240 mg/day. 1, 3

Primidone is equally effective as first-line therapy, though clinical benefits may not become apparent for 2-3 months, requiring an adequate trial period before determining efficacy. 1

Key Prescribing Considerations for Beta-Blockers

• Avoid propranolol in patients with chronic obstructive pulmonary disease, bradycardia, or congestive heart failure. 1, 2, 4
• Common adverse effects include fatigue, depression, nausea, dizziness, insomnia, cold extremities, and bronchospasm. 1
• In elderly patients, excessive heart rate reduction may lead to serious adverse events. 1
• Dual benefit: For patients with both essential tremor and hypertension, beta-blockers provide treatment for both conditions. 1

Alternative Beta-Blockers

If propranolol causes intolerable side effects, consider:

• Nadolol 40-320 mg daily 1
• Metoprolol 25-100 mg extended release daily or twice daily 1
• Timolol 20-30 mg/day 1

Second-Line Pharmacologic Options

If first-line agents fail or are not tolerated:

• Combination therapy with both propranolol and primidone can be used if either alone provides inadequate control. 5
• Gabapentin has moderate efficacy for tremor management. 1, 2
• Topiramate may be helpful in refractory cases. 5, 6

When to Initiate Treatment

Only start medications when tremor symptoms interfere with function or quality of life, not simply because tremor is present. 1, 4

Surgical Options for Medication-Refractory Tremor

Consider surgical intervention when medications fail due to lack of efficacy at maximum doses, dose-limiting side effects, medical contraindications, or occupational limitations. 1

Magnetic Resonance-Guided Focused Ultrasound (MRgFUS) Thalamotomy

• Preferred for unilateral tremor with sustained improvement of 56% at 4 years. 1, 4
• Lowest complication rate at 4.4% compared to radiofrequency thalamotomy (11.8%) and DBS (21.1%). 1, 4
• Early adverse effects include gait disturbance (36%) and paresthesias (38%), which decrease to 9% and 14% respectively by 1 year. 1
• Contraindications: Cannot undergo MRI, skull density ratio <0.40, bilateral treatment needed, or previous contralateral thalamotomy. 1, 4

Deep Brain Stimulation (DBS)

• Preferred for bilateral tremor or younger patients needing adjustable, reversible treatment. 1, 2
• Provides tremor control in approximately 90% of patients. 5
• Offers adjustable treatment that can be optimized over time. 1
• Higher complication rate (21.1%) than MRgFUS but allows for bilateral treatment. 1

Radiofrequency Thalamotomy

• Available but carries higher complication risks (11.8%) than MRgFUS. 1
• Only considered when DBS or MRgFUS are not possible. 6

Monitoring and Follow-Up

• Regular assessment of tremor severity and medication side effects is essential. 1, 2
• Dose adjustments should be made based on clinical response and tolerability. 1
• If first-line agents fail, switch to or add second-line medications before considering surgical options. 1

Important Pitfalls to Avoid

• Do not use aids or adaptive equipment in the acute phase, as they may interrupt normal automatic movement patterns and prevent future improvement. 7
• Avoid cocontraction or tensing of muscles as a method to suppress tremor, as this is unlikely to be a helpful long-term strategy. 7, 1
• Do not prescribe antiviral therapy alone or routinely order laboratory/imaging tests, as these are not indicated for essential tremor. 7