This fact sheet provides information on how to treat patients with essential tremor in different situations and circumstances.
Please note this fact sheet is only designed as a brief summary of management.
Essential tremor
Warning
Essential tremor is the most common movement disorder of adults and is defined as a bilateral arm tremor, affecting the hands and forearms, although it can affect most other body parts.
The condition used to be called ‘Benign Essential Tremor’, but changed name as it is not benign for some patients. It becomes more common as we age (around 5% over 65 years), but a younger onset (under 24 years) is recognised and affects men and women equally. Onset and progression are both subtle and the arm tremor usually happens with movement of the hand and/or arm. While the tremor may be asymmetric, it is always bilateral (as opposed to Parkinson’s Disease tremor).
In addition to the arms, the head may be affected, which helps distinguish from Parkinsons, which does not cause head tremor. Around half of patients report alcohol responsiveness and/or a family history. A variety of other neurological symptoms can occur, more recently labelled as “Essential Tremor plus” syndrome.
Whilst progressive, it is not disabling for the majority, but it can cause social embarrassment as well as fears of more lifethreatening conditions. A number of drugs can also exacerbate or cause tremor.
Key features
- Action tremor (e.g. holding cup or pen)
- Affects both arms
- Family history and alcohol responsiveness common
All patients with tremor should be tested for thyroid function.
Not necessarily if the diagnosis is obvious, but neurologists will be happy to see for diagnostic clarification or management problems.
Where appropriate, reassure the patient that they do not have a more serious condition - the most feared is Parkinson’s disease, which presents with a unilateral, rest tremor, as opposed to the bilateral kinetic tremor of essential tremor. Avoid stimulants (e.g. caffeine) if noted to exacerbate symptoms. Consider whether beta agonist inhalers or nebulisers could be a factor and whether there are alternatives. Judicial use of small amounts of alcohol may be appropriate.
Many will require nothing more than reassurance. Remind the patient that 1 in 20 over 65 years have the condition and it is rare for it to become disabling. If troublesome, then consider:
First line therapies
Propranolol MR: start at 80mg / day, this may be titrated upwards, 80 to 160mg / day usual therapeutic dose but may be increased to maximum 320mg in resistant cases if tolerated.
Primidone: start at 25mg-50mg at night (available as 50mg and 250mg tablets, halving may be difficult for people with tremor). Titrate up slowly over 4-6 weeks to maximum 750mg / day (3 times a day), however, few can tolerate this drug due to sedation. Those patients who do successfully become established on the drug, report improvement of tremor, but that they had to endure several weeks of side effects before ‘getting used’ to being on the drug. Primidone is teratogenic.
Second line therapies
Include topiramate, gabapentin, clonazepam although experience with these second line drug therapies is disappointing. People very disabled with drug resistant tremor may be considered for Deep Brain Stimulation or MRI guided focused ultrasound therapies.
The National Tremor Foundation https://tremor.org.uk/
Based on:
Shanker V. Essential tremor: diagnosis and management. BMJ. 2019 Aug 5;366:l4485 DOI: 10.1136/bmj.l4485