137
Treatments
Given the disabling character of tremor, treatment is an important aspect of the management. In
this chapter the current treatments applied for tremor disorders are discussed. Table 8.1 summarizes
the therapies.
8.1 DRUGS
The first line for treatment of tremor is oral medication. b-Blockers such as propranolol, anticho-
linergic medications, and levodopa are effective drugs for rest tremor. Kinetic tremor may slightly
respond to b-blockers, primidone, anticholinergic medication, and alcohol in case of ET (Habib-ur-
Rehman, 2000). Some ataxic patients with cerebellar cortical atrophy may exhibit a benefit with
gabapentin. Tremor associated with ataxia due to vitamin E deficiency (AVED) may respond to
supplementation.
TABLE 8.1: Main treatments for tremors
Drugs
Primidone, b-blockers, benzodiazepines, antiepileptics,
anticholinergics, levodopa and dopamine agonists, others
Lesioning surgery Thalamotomy, pallidotomy, subthalamotomy
g
-Knife
Thalamotomy
Deep brain stimulation (DBS) Main targets: thalamic ventralis intermedius nucleus (Vim),
subthalamic nucleus (STN), pallidum
Transcranial magnetic
stimulation
Motor cortical stimulation (under investigation)
Orthosis and prosthesis
Rehabilitation
Brain–machine interfaces
C H A P T E R 8
138 TREMOR
TABLE 8.2: Treatment of ET
GRADE OF SEVERITY DRUG SUGGESTED GRADE OF EFFICACY/
SIDE EFFECTS
Disabling only during
periods of stress and anxiety
Propranolol and
benzodiazepines
Disabling Either primidone or propranolol
If primidone or
propranolol do not
provide adequate control
Primidone and propranolol
in combination
Propranolol and primidone
reduce limb tremor
If propranolol induces
side effects
Consider other beta-adrenoceptor
antagonists (such as atenolol
or metoprolol)
If combination of
primidone and propranolol
do not provide adequate
control
The use of benzodiazepines
provides some benefit
–Alprazolam is probably effective
in reducing limb tremor
–Clonazepam possibly
reduces limb tremor
Other medications that
may be helpful
–Atenolol, gabapentin (monotherapy), sotalol, and topiramate
–Clozapine, nadolol, and nimodipine
–Botulinum toxin in the hand muscles in case of hand tremor
(risk of hand weakness)
Others drugs Carbonic anhydrase inhibitors
(e.g. methazolamide),
phenobarbital, clonidine,
and mirtazapine
Questionable efficacy
Disabling head or
voice tremor
Botulinum toxin injections Breathiness, hoarseness, and
swallowing difficulties may occur
in attempting to treat voice tremor
Injection should be performed in a
specialized center
If disabling tremor persists
after medication trials
Surgical options are considered Chronic DBS and thalamotomy
are usually effective
The currently available medications decrease tremor in approximately 50% of the patients. The combination of medical and surgical
therapies provide benefit in up to 80% of cases. From Lyons et al. (2003), Zesiewicz et al. (2005), and Pahwa and Lyons (2003)
TREATMENTS 139
Table 8.2 and Figure 8.1 focus on therapeutic strategies for ET. Table 8.3 lists the medica-
tions, the doses and the potential side effects (Benito-León and Louis, 2006). Drugs are presented
in detail in the text; further information about the studies quoted is given in Table 8.4.
8.1.1 Ethanol
Ethanol decreases postural essential tremor, but not parkinsonian rest tremor or the genuine cer-
ebellar kinetic tremor (which is worsened by small doses of ethanol). Ethanol improves gait ataxia
in patients with ET (Klebe et al., 2005). However, the improvement is temporary and followed by
a rebound phenomenon when the alcohol effect wears off. Recently, a case of ethanol responsive
tremor in a patient with MS has been reported (Hammond and Kerr, 2008).
FIGURE 8.1: Therapeutic strategies of essential tremor.
140 TREMOR
TABLE 8.3: Pharmacological agents and nonpharmacological procedures for the treatment of ET
PHARMACOLOGICAL
AGENTS
DOSAGE SIDE EFFECTS/COMPLICATIONS
Alprazolam 0.125–3 mg/day Sedation, fatigue, abuse
Atenolol 50–150 mg/day Light-headedness, nausea, cough, dry
mouth, sleepiness
Botulinum toxin A
(hand tremor)
50–100 U Hand or finger weakness, reduced grip
strength, pain at injection site, hematoma
Botulinum toxin A
(head tremor)
40–400 U Neck weakness, postinjection pain
Clonazepam 0.5–6 mg/day Drowsiness
Clozapine 6–75 mg/day Sedation, agranulocytosis
(risk of 0.8% at 1 year)
Gabapentin 1,200–1,800 mg/day Lethargy, fatigue, decreased libido, dizzi-
ness, nervousness, shortness of breath
Levetiracetam 1,000 mg/day Somnolence, asthenia, dizziness,
headache
Nimodipine 120 mg/day Headache, heartburn
Nadolol 120–240 mg/day None
Olanzapine 20 mg/day Drowsiness, sedation, weight gain,
diabetes
1-Octanol Up to 64 mg/kg Unusual taste sensation
Primidone Up to 750 mg/day Sedation, drowsiness, fatigue, nausea,
vomiting, ataxia, dizziness, unsteadiness,
confusion, vertigo
Propranolol 60–800 mg/day Reduced blood pressure, bradycardia,
exertional dyspnea, confusion, drowsiness,
headache, dizziness, impotency

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