Essential Tremor

Pharmacological Approaches

Drug therapy may be a reasonable option for any ET patient with disabling tremor. (Please refer to table 5.) Most (but not all) patients benefit from pharmacologic therapy, with many experiencing a significant attenuation of tremor. However, only rarely does tremor recede completely. In addition, it is possible that tolerance may be reported by some patients who are undergoing long-term therapy, potentially signifying increasing tremor severity with time.

Table 5. Drugs Used to Treat ET

Primidone (Mysoline®)

Beta-blockers such as propranolol (Inderal®)

Combination therapy (primidone and propranolol)

Benzodiazepines

Calcium channel blockers

Carbonic anhydrase inhibitors

Other tremorolytic medications

Varying degrees of control in ET have been obtained with the beta-blocker propranolol (Inderal®) and the anticonvulsant agent primidone (Mysoline®). Although neither of these agents will benefit every patient, either may be considered an appropriate first-line therapy for the symptomatic management of ET. When appropriate, these agents may be administered in combination, possibly with benzodiazepines, such as lorazepam (Ativan®) or clonazepam (Klonopin®). Additional therapeutic options that may benefit carefully selected patients include calcium channel blockers or carbonic anhydrase inhibitors.

Initiation of specific pharmacologic therapies is typically based on patient age, coexistent conditions, prior exposure to medications, concurrent drug therapies, contraindications, physician and patient bias, as well as benefits and potential adverse effects of certain agents. Drug dosage is initially low, gradually titrated upward as tolerated, and adjusted as appropriate to identify the most efficacious dose with a minimum of adverse effects (regulation of dose). If the medication is of no benefit at a dose that causes adverse effects, dose levels are gradually tapered down and therapy is eventually discontinued. If a medication is documented to be beneficial, it may be continued at the regulated doses and the next medication may be added to the drug regimen. If the response to a drug is adequate and the dose well tolerated, the physician may decide to increase the dose level (and continue to monitor tolerance).