Tremor Medication

Dr Peter Bain MA MD FRCP

Medical treatment

The currently available medical treatments for essential tremor are symptomatic and not curative. This means that the severity of essential tremor can be decreased by medication but that the tremor will not be cured. There is no medication that will permanently remove essential tremor from a person who is affected by it.

Intermittent treatment

Initially many patients prefer to receive treatment for essential tremor intermittently and not regularly. The occasional use of alcohol, propranalol, primidone or benzodiazepines (clonazepam) in high stress situations, for example important social events or work engagements, is common and the potential risks involved in taking these medications in this way are moderately small, providing that the person concerned uses these drugs in a sensible way.

Continuous treatment

1. When continuous treatment becomes necessary then it is usual to start with either:
   1. propranalol, or
   2. primidone
2. If increasing doses of either of these drugs is ineffective, a combination of both primidone and  propranolol will then usually be tried.
3. If this still does not provide sufficient benefit then alternatives include either:
   1. topiramate, or
   2. gabapentin, or
   3. clonazepam
4. Botulinum toxin treatment is sometimes considered for head or voice tremors.

Evidence based medical  treatment of essential tremor:

The evidence from carefully conducted clinical trials has been carefully analysed and made available to support the use of specific treatments for ET. The quality of the evidence to support a given treatment has been classified into the following levels:

Level A: The treatment is effective at reducing the severity of ET.

Level B: The treatment is probably effective at reducing the severity of ET.

Level C: The treatment is possibly effective at reducing the severity of ET.

Level U: There is insufficient evidence to make a recommendation about the treatment for ET.

Treatments with level A evidence from clinical trials to support their use for treating ET are:

a) Propranolol

b) Long acting propranolol

c) Primidone

Treatments with level B evidence from clinical trials to support their use for treating ET are:

a) Topiramate

b) Gabapentin

c) Atenolol

d) Sotalol

Treatments with level C evidence from clinical trials to support their use for treating ET are:

a) Clonazepam

b) Nadolol

c) Botulinum toxin (for head or voice tremor)

Treatment with level U (unproven) evidence from clinical trials to support their use for treating ET:

a) Diazepam

Other treatments

a) Alcohol (ethanol) - Alcohol will temporarily improve the tremor in 50% of ET individuals. Typically 2 units of alcohol will suppress essential tremor for about 4 hours. There is often a rebound worsening of tremor the next morning.

b) Cannabis – There is no evidence to support the use of cannabis for essential tremor.