What is the treatment for essential tremor?

Treatment for Essential Tremor

Start with propranolol (80-240 mg/day) or primidone as first-line therapy, as recommended by the American Academy of Neurology—these medications are effective in up to 70% of patients. 1

First-Line Pharmacological Treatment

The two established first-line medications are propranolol and primidone, both with comparable efficacy. 1, 2

Propranolol

• Dosing: 80-240 mg/day 1
• Most established medication with over 40 years of use 3, 1
• Only FDA-approved medication specifically for essential tremor 4
• Provides dual benefit if patient has concurrent hypertension 1

Contraindications to avoid:

• Chronic obstructive pulmonary disease 1, 5
• Bradycardia 1
• Congestive heart failure 1

Common adverse effects:

• Fatigue and depression 1
• Dizziness and hypotension 1
• Exercise intolerance and sleep disorders 1
• Cold extremities and bronchospasm 1

Primidone

• Equally effective as propranolol as first-line therapy 1, 2
• Anti-tremor properties independent of its phenobarbital metabolite 1
• Critical pitfall: Clinical benefits may not appear for 2-3 months, so ensure adequate trial period before declaring failure 1

Important warnings:

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

Alternative Beta-Blockers

If propranolol causes intolerable side effects, consider these alternatives (though less well-studied): 1, 6

• 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 but may be effective 1

Second-Line Medications

If first-line agents fail or are contraindicated:

• Combination therapy: Propranolol plus primidone 6
• Gabapentin: Limited evidence for moderate efficacy 1
• Topiramate: Mentioned as option in treatment algorithms 7, 8
• Benzodiazepines (e.g., clonazepam): Particularly useful if tremor worsens with anxiety 6, 8

When to Initiate Treatment

Only start medications when tremor interferes with function or quality of life. 1 For tremor that is disabling only during stress or anxiety, use propranolol or benzodiazepines as needed during those periods. 6

Surgical Options for Medication-Refractory Tremor

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

Treatment Algorithm for Refractory Cases:

For unilateral tremor or patients with medical comorbidities:

• Magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy is preferred 1
• Shows sustained tremor improvement of 56% at 4 years 1
• Lower complication rate (4.4%) compared to radiofrequency thalamotomy (11.8%) and DBS (21.1%) 1, 5
• Early adverse effects include gait disturbance (36%) and paresthesias (38%), decreasing to 9% and 14% by 1 year 1

MRgFUS contraindications:

• Cannot undergo MRI 1
• Skull density ratio <0.40 1
• Bilateral treatment needed 1
• Previous contralateral thalamotomy 1

For bilateral tremor or MRgFUS contraindications:

• Deep brain stimulation (DBS) of the ventral intermediate nucleus of thalamus 1, 7
• Provides adjustable, reversible tremor control that can be optimized over time 1
• Approximately 90% tremor control rate 6
• Preferred for younger patients as it offers adjustability 1
• FDA-approved since 1997 4

Monitoring and Dose Titration

• Regularly assess tremor severity and medication side effects 1
• Adjust doses based on clinical response and tolerability 1
• If first-line agents fail, switch to or add second-line medications before considering surgery 1
• In elderly patients, monitor closely for excessive heart rate reduction with beta-blockers, which can lead to serious adverse events 1