Essential Tremor

Sequential Approach to the Management of Essential Tremor

In most patients, the various approaches to the treatment of ET are implemented in a sequential manner. Pharmacologic treatment typically begins with primidone or propranolol monotherapy with appropriate upward titration. This treatment approach for ET patients is summarized in table 9.

Table 9. Sequential Treatment Approach for Essential Tremor

Initiate drug therapy by: Selecting an appropriate pharmacologic agent: Primidone (12.5 to 25 mg/day PO at bedtime). Increase dose gradually in 25 mg increments to an upper limit of 125 to 250 mg/day. or Propranolol (10 to 60 mg/day PO). Increase dose gradually in 20 mg increments to an upper limit of 120 mg/day up to 320 mg/day. or A benzodiazepine (e.g., clonazepam at a starting dose of 0.25 mg/day PO that may be slowly increased to 1.0 to 2.0 mg/day in divided doses). Regulation of drug dose: identify the most efficacious dose with a minimum of adverse effects. If the medication is of no benefit at a dose that causes adverse effects, gradually taper down and discontinue. If a medication is documented to be helpful, continue at the regulated dose and add the next medication to attempt achieving further benefit.

If necessary, switch from propranolol to long-acting propranolol 80 mg/day. Increase in 60 or 80 mg increments as needed up to 160 to 320 mg/day.

If tremor control remains inadequate on monotherapy, initiate combination therapy.

If pharmacologic therapy is inadequate and the patient is an appropriate candidate, consider local injections of botulinum toxin.

If medical therapy fails, consider stereotactic surgery such as thalamotomy or DBS.

It is important to note that, as with any invasive procedure, there are surgical risks associated with both thalamotomy and DBS (e.g., stroke, hemorrhage, permanent speech impairment, etc.).