Tremor medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Zehra Malik, M.B.B.S[2]

The mainstay of treatment for tremor is to recognize the type of tremor and underlying etiology and then treat is appropriately. Tremor cannot be cured but it can be managed optimally with indicated medications and non-pharmacological therapy.

Non-pharmacological Therapy

• These may help minimize tremor regardless of the cause. Basis of non pharmacological therapy includes:
  • Lifestyle changes: Limiting tremor-provoking substances such as caffeine and medication.
  • Physical therapy: Physical, speech-language, occupational therapy.
  • Psychological techniques: Relaxation techniques, biofeedback.

Pharmacological Therapy

• Essential tremor:
  • First line medications are propranolol (40 to 240 mg/day) or primidone (initiated at 12.5 mg daily, titrated gradually to the dose of 50 and 750 mg daily – divided into BID or TID). ^[1]
  • If not effective individually then these two medications should be tried in combination.
  • Second line medications include gabapentin, pregabalin, topiramate, beta-blockers (atenolol and metoprolol), benzodiazepines (clonazepam, alprazolam).
  • Third line medications include nimodipine and clozapine. ^[2]
  • Alcohol does help come patients in minimizing tremor and some patients have noticed rebound worsening after the effect of alcohol fades. ^[3]
• Parkinson’s disease: ^[4][5]
  • First-line: Carbidopa–levodopa in combination, as carbidopa prevents conversion of levodopa into dopamine before reaching the brain, hence increasing efficacy.
  • Dopamine agonists: Mimics dopamine effect on the brain. Not as effective as levodopa,
  • MAO B inhibitors:Selegiline, rasagiline, safinamide. These prevent dopamine breakdown in brain by inhibiting monoamine oxidase B enzyme.
  • Catechol O-methyltransferase (COMT) inhibitors: Entacapone, opicapone. Increases efficacy of levodopa by preventing metabolism.
  • Anticholinergics: Benztropine, trihexyphenidyl. Minimizes tremor associated with Parkinson’s disease.
• Physiologic Tremor:
  • Factors than enhance a physiological tremor must be controlled.
  • Propranolol can be take prophylactically to prevent enhanced physiologic tremor in situations that trigger it.
• Multiple Sclerosis:
  • Beta-blockers, anxiolytics, anticonvulsants can help minimize MS-related tremors.
• Orthostatic Tremor: ^[6]
  • First line: Clonazepam, should be started at 0.5mg and titrated up to 2mg thrice a day.
  • Second line: Gabapentin (300 to 2400mg/day), sodium valproate, carbamazepine, phenobarbital.
• Alcohol withdrawal tremor:
  • Hydration, folate, thiamine, multivitamin, benzodiazepine ^[7]