Essential Tremor

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Essential Tremor
As with other tremors, effective treatment of essential tremor is not found in a single, universal agent. Some therapies may be satisfactory in some patients and ineffective in others. The most widely used drugs for essential tremor are the beta-adrenergic blocker propranolol (Inderal) and the anticonvulsant primidone (Mysoline). The typical dosage range for propranolol is 80 to 320 mg per day and for primidone, 25 to 750 mg per day.³ Other beta-adrenergic receptor antagonists used in the treatment of essential tremor include metoprolol (Lopressor) and nadolol (Corgard).² Alcohol is also effective in relieving essential tremor, but abuse may be an adverse consequence.³

In our experience, propranolol and primidone are equally effective in the treatment of essential tremor. Patients who do not respond to one medication after a few weeks of therapy should be tried on the other one. Primidone may be preferred, because of the exercise intolerance associated with high-dose beta blockade. Patients who have a very-low-amplitude rapid tremor are generally more responsive to these agents than those who have a slower tremor with greater amplitude. Patients who have tremor of the head and voice may also be more resistant to treatment than patients with essential tremor of the hands.

Other Tremors
There is no established treatment for cerebellar tremor.² In patients with multiple sclerosis, severe cerebellar tremor may be improved with isoniazid, in a dosage of 600 to 1,200 mg per day, given together with pyridoxine.⁴

Propranolol in a dosage of 160 mg per day is very effective in reducing the tremor associated with alcohol withdrawal.¹⁰

Thalamic stimulation by means of an implanted electrode may effectively control tremor in patients with essential tremor or Parkinson's disease.

Treatment of orthostatic tremor should first be attempted with clonazepam (Klonopin). In one small study,¹⁴ eight of nine patients responded to clonazepam in dosages ranging from 0.5 to 2.0 mg per day. The patient who did not respond to clonazepam responded to chlordiazepoxide (Librium), in a dosage of 30 mg twice a day. In another study,¹² 10 of 18 patients had sustained improvement with clonazepam, and valproic acid was effective in the remaining eight patients. However, propranolol in daily dosages of up to 320 mg had no effect on controlling orthostatic tremor.

Tremor due to peripheral neuropathy may be ameliorated with propranolol, primidone, benzodiazepines or baclofen (Lioresal), but the underlying cause of the neuropathy itself should be treated as well.²

Other medications have been shown to be helpful in the management of tremor but should probably only be tried in consultation with a neurologist, when the previously mentioned drugs have failed to control the tremor.

Surgical Treatment of Tremor

Thalamotomy
Surgical therapy for tremor should only be considered if drug therapy fails to produce adequate relief. Stereotactic thalamotomy is the surgical procedure most often used to quell essential tremor. Before the introduction of levodopa, thalamotomy was an often-selected option in the treatment of Parkinson's disease. Because the benefits of levodopa wane after four to seven years of therapy, this procedure remains an option in some patients with severe parkinsonian tremor refractory to drug therapy. However, problems associated with bilateral thalamotomy, such as dysphagia and dysarthria, limit its use. Thalamotomy is usually only considered in patients with severe, drug-resistant essential tremor and in a very small subset of patients with Parkinson's disease who have severe, disabling, predominantly unilateral tremor.

In one study of the use of stereotactic thalamotomy in the treatment of tremor,¹⁷ 86 percent of the 42 patients with parkinsonian tremor and 83 percent of the six patients with essential tremor had cessation of tremor or moderate to marked improvement in tremor after the procedure. Follow-up in some patients was as long as 13 years (mean follow-up: 53.4 months). The investigators used three criteria for patient selection: (1) predominantly unilateral, severe and incapacitating tremor, (2) a poor response to or intolerance of optimal medical therapy and (3) no potentially serious risk factors for surgery. Postoperative complications included weakness, dysarthria and confusion, but these problems subsided with time.

Catastrophic complications in the perioperative period include bleeding in the thalamus or the subdural or epidural area, which can lead to death, paralysis, aphasia or significant cognifive deficits.

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