What is the first‑line medication regimen for an adult with essential tremor who has no contraindications to beta‑blockers?

First-Line Medication for Essential Tremor

Propranolol is the first-line medication for adults with essential tremor who have no contraindications to beta-blockers, with a typical dosing range of 80-240 mg daily, though most patients achieve adequate control at 160 mg daily. 1, 2

Rationale for Propranolol as First-Line

• Propranolol has been the most established medication for essential tremor for over 40 years, with demonstrated efficacy in up to 70% of patients. 1, 2
• The American Academy of Neurology specifically recommends propranolol as first-line treatment alongside primidone. 1
• Propranolol is a non-selective beta-blocker without intrinsic sympathomimetic activity (ISA), which is critical for tremor control—beta-blockers with ISA (acebutolol, pindolol, oxprenolol) are ineffective for tremor and should be avoided. 3, 4

Dosing Strategy

• Start propranolol at 40 mg twice daily and titrate upward based on tremor response and tolerability. 1
• The therapeutic range is 80-240 mg daily in divided doses, with most patients responding adequately at 160 mg daily. 1, 3
• Clinical benefits may take several weeks to become fully apparent, so allow 2-3 months for an adequate trial before declaring treatment failure. 5

Alternative First-Line Option: Primidone

• Primidone is equally recommended as first-line therapy by the American Academy of Neurology and may be preferred when beta-blockers are contraindicated. 1, 2
• Primidone has anti-tremor properties independent of its conversion to phenobarbital, with therapeutic benefit occurring even when phenobarbital levels remain subtherapeutic. 1
• Common side effects include behavioral disturbances, irritability, and sleep disturbances, particularly at higher doses. 1
• Women of childbearing age require counseling about teratogenic risks (neural tube defects). 1

Critical Contraindications to Propranolol

Before prescribing propranolol, screen for the following absolute contraindications:

• Asthma or chronic obstructive pulmonary disease (COPD) due to risk of bronchospasm from beta-2 blockade. 1, 6, 3
• Decompensated heart failure (though compensated heart failure may allow cautious use with close monitoring). 1, 3
• Second- or third-degree heart block, sick sinus syndrome without pacemaker, or sinus bradycardia (<50 bpm). 3
• First-degree AV block warrants significant caution, as beta-blockers can worsen AV conduction delay. 6

Monitoring and Follow-Up

• Assess tremor severity and medication side effects regularly, with dose adjustments based on clinical response and tolerability. 1
• Monitor for common adverse effects including fatigue, depression, dizziness, hypotension, cold extremities, and sleep disorders. 1, 3
• In elderly patients, excessive heart rate reduction may lead to serious adverse events. 1
• Do not abruptly discontinue propranolol after regular use, as this can cause rebound symptoms. 3

When First-Line Therapy Fails

• If propranolol or primidone fail at maximum tolerated doses, consider switching to the alternative first-line agent before moving to second-line options. 1
• Second-line medications include gabapentin, topiramate, and benzodiazepines, though evidence for these is more limited. 1, 7
• Combination therapy (polypharmacy) may be effective in some cases when monotherapy is insufficient. 7
• Surgical options (deep brain stimulation or MRgFUS thalamotomy) should be considered when medications fail due to lack of efficacy, side effects, or contraindications. 1

Special Considerations

• For patients with both essential tremor and hypertension, propranolol provides dual therapeutic benefits. 1
• In patients with diabetes, propranolol can mask hypoglycemia symptoms (tachycardia, tremor); counsel patients to increase glucose monitoring frequency and rely on non-adrenergic warning signs like sweating and confusion. 3
• Medications for essential tremor should only be initiated when tremor symptoms interfere with function or quality of life. 1