Medications for Tremor Treatment
For essential tremor, start with either propranolol (80-240 mg/day) or primidone as first-line therapy, as these are the only medications with strong evidence for efficacy and are effective in up to 70% of patients. 1, 2
First-Line Treatment Options
Propranolol is the most established medication for essential tremor with over 40 years of demonstrated efficacy 1. The recommended dosage is 80-240 mg/day 3, 1. This beta-blocker without intrinsic sympathomimetic activity provides approximately 50% tremor reduction on average 4.
Primidone is equally effective as propranolol and serves as an alternative first-line option 1, 2. Clinical benefits may not become apparent for 2-3 months, requiring an adequate trial period 2. Therapeutic benefit can occur even when derived phenobarbital levels remain subtherapeutic, confirming primidone itself has anti-tremor properties 2.
Critical Contraindications for Propranolol:
- Chronic obstructive pulmonary disease or asthma (risk of bronchospasm) 1, 2
- Bradycardia or heart block 1
- Decompensated congestive heart failure 1, 2
Second-Line Medications
If propranolol and primidone fail individually, combine both medications before moving to other options 5.
Alternative beta-blockers can be tried if propranolol causes adverse effects 5:
- Metoprolol: 25-100 mg extended release daily or twice daily 1
- Atenolol: limited evidence for moderate effect 1, 5
- Nadolol: 40-320 mg daily 1
- Timolol: 20-30 mg/day 1
Other second-line options include 3, 2:
- Topiramate (supported by large double-blind placebo-controlled trial) 4
- Gabapentin (limited evidence for moderate efficacy) 1, 5
- Benzodiazepines such as clonazepam (particularly useful when tremor is disabling only during stress/anxiety periods) 5, 6
Special Tremor Types
For head or voice tremor: Botulinum toxin injections into affected muscles provide relief 5, 4. This is the most effective treatment for these tremor locations 7.
For dystonic limb tremor: Anticholinergics may be effective 4.
Treatment Initiation Guidelines
Only initiate medication when tremor symptoms interfere with function or quality of life 1, 2. For patients with intermittent disability only during stressful occasions, use propranolol, clonazepam, or primidone monotherapy on an as-needed basis 6.
Common Pitfalls
Beta-blocker adverse effects include fatigue, depression, nausea, dizziness, insomnia, cold extremities, and bronchospasm 1. In elderly patients, excessive heart rate reduction may lead to serious adverse events 1.
Primidone side effects include behavioral disturbances, irritability, and sleep disturbances at higher doses 2. Women of childbearing age require counseling about teratogenic risks (neural tube defects) 2.
When Medications Fail
If tremor remains disabling after adequate trials of propranolol and primidone (both individually and in combination), consider surgical options 2, 5:
- Deep brain stimulation (DBS) provides approximately 90% tremor control with fewer complications than ablative procedures 5, 7
- Magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy shows 56% sustained tremor improvement at 4 years with lower complication rates (4.4%) compared to DBS (21.1%) 1, 2
Monitoring Requirements
Regular assessment of tremor severity and medication side effects is essential 1, 2. Dose adjustments should be made based on clinical response and tolerability 1. If first-line agents fail, switch to or add second-line medications before considering surgical options 1.