What are the treatment options for episodes of shaking?

Treatment of Episodes of Shaking

The treatment of shaking episodes depends critically on the underlying cause: for essential tremor, propranolol is first-line; for Parkinsonian rest tremor, levodopa/carbidopa is indicated; for reflex syncope with shaking, physical counterpressure maneuvers and education are primary interventions; and for positional vertigo causing shaking sensations, canalith repositioning maneuvers (Epley) are definitive treatment. 1, 2, 3

Diagnostic Framework to Guide Treatment

Before initiating treatment, determine the tremor/shaking type through these specific features:

• Resting tremor (present at rest, disappears with movement): characteristic of Parkinson's disease 1, 2
• Action/postural tremor (maximal when hands outstretched, persists during movement): characteristic of essential tremor 1, 2
• Intention tremor (occurs only with movement): indicates cerebellar disease 1
• Whole body shaking with loss of consciousness: consider reflex syncope or seizure 3
• Shaking triggered by positional changes with vertigo: consider benign paroxysmal positional vertigo 3

Treatment by Tremor Type

Essential Tremor (Action/Postural Tremor)

Propranolol is the first-line pharmacological treatment for essential tremor, providing effective symptom control in many patients. 2, 4

• Propranolol reduces postural and kinetic tremors involving hands, head, and voice 2
• Primidone is an alternative first-line agent when propranolol is contraindicated or ineffective 2, 4
• Approximately 50% of essential tremor cases are hereditary 2
• For refractory cases causing significant disability, consider deep brain stimulation, focused ultrasound thalamotomy, or transcranial magnetic stimulation 4

Parkinsonian Rest Tremor

Levodopa (with carbidopa) is the primary treatment for Parkinsonian rest tremor, usually providing significant tremor reduction. 5, 1, 2

• Levodopa/carbidopa effectively treats the characteristic resting tremor that disappears with movement 1, 2
• Anticholinergics may decrease tremor but frequently cause mental side effects in elderly patients and should be avoided in this population 2
• Critical warning: When reducing or discontinuing levodopa, observe patients carefully for neuroleptic malignant syndrome (NMS)—a life-threatening condition characterized by fever, muscle rigidity, altered consciousness, and autonomic dysfunction 5
• Patients should be cautioned about potential somnolence and sudden sleep onset; those experiencing significant daytime sleepiness should not drive 5

Cerebellar Intention Tremor

Pharmacologic agents are not helpful for intention tremor; stereotaxic surgery is the only known effective treatment. 1

• Intention tremor occurs only with movement and indicates cerebellar pathology 1
• Medical management is ineffective for this tremor type 1

Treatment for Shaking Associated with Syncope

Reflex Syncope with Convulsive Movements

Physical counterpressure maneuvers (PCMs) are the primary non-pharmacological treatment, reducing syncope recurrence by 39% with no adverse events. 3

Education and trigger avoidance form the cornerstone of management:

• Educate patients about the benign nature of reflex syncope 3
• Train patients to recognize prodromal symptoms early 3
• Teach avoidance of triggers: hot crowded environments, volume depletion, prolonged standing 3

Physical counterpressure maneuvers (when prodrome recognized):

• Leg crossing with isometric contraction 3
• Hand grip and arm tensing 3
• These maneuvers induce significant blood pressure increases that prevent or delay loss of consciousness 3
• In a multicenter trial, 32% of patients trained in PCMs experienced syncope recurrence versus 51% with conventional therapy alone (P < 0.005) 3

Pharmacological therapy has limited evidence:

• Beta-blockers, midodrine, and fludrocortisone have shown disappointing results in long-term placebo-controlled trials 3
• Avoid etilefrine—no difference from placebo in preventing recurrent syncope 3
• Midodrine showed positive results only in small trials with frequent symptoms, but compliance is limited by frequent dosing 3

Tilt training:

• May reduce syncope in highly motivated young patients with orthostatic triggers 3
• Hampered by poor long-term compliance 3
• Four randomized trials failed to confirm short-term effectiveness 3

Treatment for Positional Vertigo with Shaking Sensations

Canalith repositioning maneuvers (Epley maneuver) are the definitive treatment for benign paroxysmal positional vertigo, with high success rates and minimal adverse effects. 3

• The Epley maneuver and its modifications are highly effective for posterior canal BPPV (85-95% of cases) 3
• Semont and Gufoni maneuvers are alternative repositioning techniques 3
• Patient self-treatment with home-based maneuvers is appropriate after initial training 3
• Avoid vestibular suppressant medications and benzodiazepines—these do not address the underlying pathology 3
• Brandt-Daroff exercises may be used as adjunctive therapy 3

Special Considerations and Pitfalls

For vascular causes of whole body shaking:

• Rare cases of whole body shaking may result from bilateral intracranial blood flow steal in the setting of severe stenoocclusive disease 6
• These require aggressive medical therapy and potentially angioplasty rather than tremor-specific medications 6

Common pitfalls to avoid:

• Do not misdiagnose essential tremor (action tremor) as Parkinson's disease—propranolol, not levodopa, is appropriate 1, 2
• Do not use pharmacologic agents for cerebellar intention tremor—they are ineffective 1
• Do not prescribe vestibular suppressants for BPPV—repositioning maneuvers are curative 3
• Do not abruptly discontinue levodopa without careful monitoring for NMS 5
• Avoid anticholinergics in elderly patients with Parkinsonian tremor due to cognitive side effects 2