Initial Treatment for Essential Tremor
Propranolol (80-240 mg/day) or primidone are the first-line treatments for essential tremor, with both demonstrating efficacy in approximately 50-70% of patients. 1, 2
First-Line Medication Selection
The American Academy of Neurology recommends either propranolol or primidone as initial therapy, and you should choose between them based on patient-specific contraindications and comorbidities 1, 2:
Choose Propranolol When:
- Patient has concurrent hypertension (provides dual benefit) 1
- Tremor is intermittent or stress-related (can be used as needed) 3
- Patient needs faster onset of action 1
Propranolol dosing: Start at 80 mg/day and titrate up to 240 mg/day as needed 1, 2
Choose Primidone When:
- Patient has asthma, COPD, or other respiratory disease 1, 4
- Patient has bradycardia (<50 bpm), heart block, or decompensated heart failure 1, 2
- Patient has failed propranolol or cannot tolerate beta-blockers 1
Primidone dosing: Clinical benefits may not appear for 2-3 months, so ensure an adequate trial period 2, 5
Critical Contraindications to Propranolol
Absolute contraindications include 2, 4:
- Asthma or COPD (risk of bronchospasm)
- Decompensated heart failure
- Second- or third-degree heart block
- Sick sinus syndrome without pacemaker
- Sinus bradycardia (<50 bpm)
When to Initiate Treatment
Only start medication when tremor interferes with function or quality of life 1, 2. Essential tremor can cause greater functional impairment than Parkinson's disease in activities like writing, eating, drinking, and reading 4.
If First-Line Agents Fail
Combination therapy: If monotherapy with propranolol or primidone provides inadequate control, use both medications together 6, 7
Alternative beta-blockers: If propranolol causes adverse effects, try atenolol (25-100 mg) or metoprolol (25-100 mg extended release) 1, 8
Second-line options include 1, 5:
- Topiramate (probably effective)
- Gabapentin (limited evidence for moderate efficacy)
- Benzodiazepines like clonazepam or alprazolam (particularly if anxiety is present)
Important Monitoring Considerations
- Regular assessment of tremor severity and medication side effects is essential 1, 2
- Propranolol may cause lethargy, depression, dizziness, hypotension, and exercise intolerance 1
- Primidone can cause behavioral disturbances, irritability, and sleep disturbances at higher doses 1
- Women of childbearing age on primidone require counseling about teratogenic risks (neural tube defects) 1, 2
- Therapeutic benefit from primidone can occur even when phenobarbital levels remain subtherapeutic 1, 2
Surgical Referral Criteria
Consider surgical options (MRgFUS thalamotomy or deep brain stimulation) when medications fail due to lack of efficacy at maximum doses, dose-limiting side effects, or medical contraindications 1, 2. MRgFUS shows sustained tremor improvement of 56% at 4 years with lower complication rates (4.4%) compared to other surgical options 1, 4.