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Benefits and Risks of Pharmacological Treatments for Essential Tremor

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Abstract

Essential tremor can cause significant functional disability in some patients. The arms are the most common body part affected and cause the most functional disability. The treatment of essential tremor includes medications, surgical options and other forms of therapy. Presently there is no cure for essential tremor nor are there any medications that can slow the progression of tremor.

Treatment for essential tremor is recommended if the tremor causes functional disability. If the tremor is disabling only during periods of stress and anxiety, propranolol and benzodiazepines can be used during those periods when the tremor causes functional disability. The currently available medications can improve tremor in approximately 50% of the patients. If the tremor is disabling, treatment should be initiated with either primidone or propranolol. If either primidone or propranolol do not provide adequate control of the tremor, then the medications can be used in combination. If patients experience adverse effects with propranolol, occasionally other β-adrenoceptor antagonists (such as atenolol or metoprolol) can be used. If primidone and propranolol do not provide adequate control of tremor, occasionally the use of benzodiazepines (such as clonazepam) can provide benefit. Other medications that may be helpful include gabapentin or topiramate. If a patient has disabling head or voice tremor, botulinum toxin injections into the muscles may provide relief from the tremor. Botulinum toxin in the hand muscles for hand tremor can result in bothersome hand weakness and is not widely used. There are other medications that have been tried in essential tremor and have questionable efficacy. These drugs include carbonic anhydrase inhibitors (e.g. methazolamide), phenobarbital, calcium channel antagonists (e.g. nimodipine), isoniazid, clonidine, clozapine and mirtazapine.

If the patient still has disabling tremor after medication trials, surgical options are usually considered. Surgical options include thalamotomy and deep brain stimulation of the thalamus. These surgical options provide adequate tremor control in approximately 90% of the patients. Surgical morbidity and mortality for these procedures is low. Deep brain stimulation and thalamotomy have been shown to have comparable efficacy but fewer complications have been reported with deep brain stimulation. In patients undergoing bilateral procedures deep brain stimulation of the thalamus is the procedure of choice to avoid adverse effects seen with bilateral ablative procedures. The use of medication and/or surgery can provide adequate tremor control in the majority of the patients.

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Notes

  1. Use of tradenames is for product identification only and does not imply endorsement.

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Acknowledgements

No sources of funding were used to assist in the preparation of this manuscript. The authors have reported the following conflicts of interest: Kelly Lyons — consultant Medtronic; Rajesh Pahwa — consultant Medtronic, speaker Medtronic, Novartis, investigator Ortho McNeil; Cynthia Comella — consultant Elan, Allergan, speaker Elan, Allergan, research grants Elan, Allergan; Joseph Jankovic — research grants Medtronic, Allergan; William Koller — consultant Medtronic, Elan, Novartis, speaker Novartis; William Ondo — speaker Allergan; investigator Ortho McNeil; Kapil Sethi — consultant Elan, Novartis, research grants Novartis, Elan, speaker Elan; Ray Watts — consultant and speaker Novartis.

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Authors and Affiliations

  1. Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, Kansas, KS 66160-7314, USA

    Kelly E. Lyons &  Rajesh Pahwa

  2. Rush Presbyterian St. Luke’s Medical Center, Chicago, Illinois, USA

    Cynthia L. Comella

  3. Pennsylvania Hospital, Philadelphia, Pennsylvania, USA

    Mahmood S. Eisa & Matthew B. Stern

  4. Southern Illinois University School of Medicine, Springfield, Illinois, USA

    Rodger J. Elble

  5. Columbia University, New York, New York, USA

    Stanley Fahn

  6. Baylor College of Medicine, Houston, Texas, USA

    Joseph Jankovic, William G. Ondo & Ron Tintner

  7. Emory University, Atlanta, Georgia, USA

    Jorge L. Juncos & Ray L. Watts

  8. Mt. Sinai Medical Center, New York, New York, USA

    William C. Koller

  9. Medical College of Georgia, Augusta, Georgia, USA

    Kapil D. Sethi

  10. The Parkinson Institute, Sunnyvale, California, USA

    Caroline M. Tanner

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  1. Kelly E. Lyons
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  2. Rajesh Pahwa
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Correspondence to Rajesh Pahwa.

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Lyons, K.E., Pahwa, R., Comella, C.L. et al. Benefits and Risks of Pharmacological Treatments for Essential Tremor. Drug-Safety 26, 461–481 (2003). https://doi.org/10.2165/00002018-200326070-00003

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