What medications are used to treat essential tremors?

Medications for Essential Tremor

Propranolol (80-240 mg/day) or primidone are the first-line medications for essential tremor, recommended by the American Academy of Neurology, with demonstrated efficacy in up to 70% of patients. 1

First-Line Treatment Options

Propranolol (Preferred Beta-Blocker)

• Propranolol is the most established medication for essential tremor, having been used for over 40 years with proven efficacy 1
• Dosage range: 80-240 mg/day 1, 2
• Effective in approximately 50-70% of patients 1, 3
• Contraindications: Avoid in patients with chronic obstructive pulmonary disease, bradycardia, or congestive heart failure 1, 2, 4
• Common adverse effects include fatigue, depression, dizziness, hypotension, exercise intolerance, sleep disorders, cold extremities, and bronchospasm 1, 2
• In elderly patients, excessive heart rate reduction may lead to serious adverse events 1
• Dual benefit: For patients with both essential tremor and hypertension, propranolol addresses both conditions simultaneously 1, 4

Primidone (Alternative First-Line)

• Equally effective as propranolol as first-line therapy 1, 5
• Therapeutic benefit can occur even when derived phenobarbital levels remain subtherapeutic, confirming primidone itself has anti-tremor properties 1
• Clinical benefits may not become apparent for 2-3 months, so an adequate trial period is essential 1
• Side effects include behavioral disturbances, irritability, and sleep disturbances, particularly at higher doses 1
• Women of childbearing age must be counseled about teratogenic risks (neural tube defects) 1, 6
• FDA warning: Increased risk of suicidal thoughts and behavior with all antiepileptic drugs, including primidone 6

Combination Therapy

• If either propranolol or primidone alone provides inadequate tremor control, they can be used in combination 3

Alternative Beta-Blockers (If Propranolol Not Tolerated)

• Nadolol: 40-320 mg daily 1
• Metoprolol: 25-100 mg extended release daily or twice daily 1
• Atenolol: Limited evidence for moderate effect; common adverse effects include fatigue, depression, nausea, dizziness, and insomnia 1
• Timolol: 20-30 mg/day 1

Second-Line Medications

When First-Line Agents Fail

• Carbamazepine may be used as second-line therapy, though generally not as effective as first-line options 1
• Gabapentin has limited evidence for moderate efficacy in tremor management 1, 2
• Topiramate can be considered 7, 8
• Benzodiazepines (such as clonazepam) can provide benefit, particularly in patients with associated anxiety 3, 8

Treatment Initiation Criteria

Medications for essential tremor are only initiated when tremor symptoms interfere with function or quality of life 1, 4

Monitoring and Dose Adjustments

• Regular assessment of tremor severity and medication side effects is essential 1
• Dose adjustments may be needed based on clinical response and tolerability 1
• If first-line agents fail, consider switching to or adding second-line medications before considering surgical options 1

Surgical Options for Medication-Refractory Tremor

When medications fail due to lack of efficacy at maximum doses, dose-limiting side effects, or medical contraindications, surgical therapies should be considered 1, 2

Magnetic Resonance-Guided Focused Ultrasound (MRgFUS) Thalamotomy

• Shows sustained tremor improvement of 56% at 4 years 1, 2, 4
• Lower complication rate (4.4%) compared to radiofrequency thalamotomy (11.8%) and deep brain stimulation (21.1%) 1, 2, 4
• Contraindications: Cannot be used bilaterally, contralateral to previous thalamotomy, in patients unable to undergo MRI, or with skull density ratio <0.40 1, 4
• Preferred for unilateral tremor or patients with medical comorbidities 1

Deep Brain Stimulation (DBS)

• Preferred for bilateral tremor involvement 1
• Provides adjustable, reversible tremor control that can be optimized over time 1
• Approximately 90% tremor control rate 3

Radiofrequency Thalamotomy

• Available but carries higher complication risks than MRgFUS 1

Common Pitfalls to Avoid

• Do not prescribe aids and equipment for tremor in the acute phase, as they may interrupt normal automatic movement patterns 1
• Do not discontinue anticonvulsants abruptly in pregnant women with epilepsy, as this may precipitate status epilepticus 6
• Pregnant women on primidone should receive prophylactic vitamin K1 therapy for 1 month prior to and during delivery to prevent neonatal hemorrhage 6