Propranolol for Essential Tremor
Start propranolol at 40 mg twice daily (immediate-release) or 80 mg once daily (long-acting formulation), then titrate upward every 1-2 weeks based on tremor response to a target maintenance dose of 120-320 mg daily, with most patients achieving optimal benefit at 240-320 mg daily. 1
Pre-Treatment Assessment
Before initiating propranolol, you must screen for absolute contraindications:
- Second or third-degree heart block 2, 3
- Decompensated heart failure 2, 3
- Asthma or obstructive airway disease 2, 3
- Cardiogenic shock or sinus node dysfunction without pacemaker 2
Perform baseline cardiovascular assessment including:
- Heart rate and blood pressure measurement 2, 3
- Cardiovascular examination with auscultation 2
- Screen for history of bronchospasm, diabetes, and concurrent medications affecting cardiac conduction 2, 3
Note that routine ECG is not required in otherwise healthy adults without cardiac concerns 3, though the American Academy of Pediatrics recommends ECG in younger patients or those with abnormal cardiac findings 2
Dosing Strategy
Initial Dosing
- Immediate-release formulation: Start 40 mg twice daily 2
- Long-acting formulation: Start 80 mg once daily 2, 4
- Administer with food to reduce hypoglycemia risk 2, 3
Titration Approach
- Increase dose every 1-2 weeks based on tremor response 2
- Wait minimum 24 hours between dose increases when monitoring for adverse effects 3
- Monitor heart rate and blood pressure before each dose increase, particularly watching for bradycardia and hypotension 3
Target Maintenance Dose
The optimal therapeutic dose for essential tremor is 240-320 mg daily 1, which is notably higher than doses used for other indications. Research demonstrates that many patients receive suboptimal doses and consequently miss the best therapeutic effect 1. The maximum dose can reach 640 mg daily if needed 2, though most patients respond well at lower doses.
Long-acting propranolol is preferred by 87% of patients for ease of administration and provides similar or greater tremor reduction compared to divided dosing 4, making it an excellent choice for long-term management.
Clinical Response Patterns
- Most patients show considerable tremor reduction at relatively low doses, often with unmeasurable plasma propranolol concentrations 5
- Improvement is most pronounced in upper extremity tremor 6
- Plasma propranolol levels do not correlate with clinical effect, so dosing should be guided by clinical tremor evaluation rather than drug levels 5
- Three-times-daily dosing may minimize abrupt changes in blood pressure and heart rate if using immediate-release formulation 3
Monitoring During Treatment
- Monitor for hypotension and bradycardia, especially during dose escalation 2, 3
- Check vital signs 30 minutes after first dose in high-risk patients 3
- No routine vital sign monitoring required between appointments if patient is stable and asymptomatic 2
- Hold doses during periods of diminished oral intake or vomiting 2, 3
Common Adverse Effects
Watch for:
- Fatigue, bradycardia, hypotension 2, 3
- Dizziness and cold extremities 2, 3
- Masking of hypoglycemia symptoms in diabetic patients 2
- Temporarily discontinue if patient develops wheezing requiring treatment 3
Critical Safety Considerations
Never abruptly discontinue propranolol after chronic use 2, 3. Taper gradually over several weeks (1-3 weeks recommended) to prevent:
Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block 2, 3
Long-Term Efficacy
Response to propranolol in essential tremor varies:
- Excellent response maintained for up to 4 years in some patients 7
- Response tends to deteriorate with time if initially less than excellent 7
- Younger patients (under 55 years) with shorter tremor duration (less than 12 years) have best long-term outcomes 7
- No patients 60 years or older achieved excellent response in long-term studies 7
If no significant response after 3 months at 120 mg daily, consider decreasing dose and discontinuing 7, as continued escalation is unlikely to provide benefit in true non-responders.