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benign essential tremor

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Essential tremor is a visible postural tremor of hands and forearms. It may include a kinetic component.(1)

It is the most common movement disorder (1)

Essential tremor is a 6-8 Hz tremor that is of variable amplitude.

Other features are:

  • aggravation by posture and movement
  • relief by rest and alcohol - improvement lasting about two hours
  • most affected are the arms, head and vocal apparatus
  • associated features are:
    • no rigidity
    • no cerebellar signs
    • familial condition
  • often a response to beta-blockers including propranolol

Essential tremor superimposes a waveform on top of an accurate movement and thus is distinct from intention tremor.

Management:

  • neurology referral is required for diagnosis and subsequent treatment plan
  • therapeutic options - there is no evidence relating to the long-term efficacy of any treatment measures used in the management of essential tremor (2,3). Various drug treatments have been used in this condition and have evidence of effectiveness in the short term only. These include:
    • ß Blockers - including propranolol, atenolol and sotalol
    • benzodiazepines
    • botulinum A toxin-haemagglutinin complex
    • flunarizine
    • phenobarbital
    • primidone
    • topiramate
    • gabapentin
    • pregabalin

  • beta blockers are generally the first line treatment e.g. propranolol (start low dose and titrate to maximum 40mg bd). Many neurologists would suggest primidone as a first-line alternative to propranolol e.g. in a patient with asthma (2,3)
    • often patients will find the first dose of primidone difficult to tolerate - a suggested regime would be a quarter of a 250mg tablet at night, building up very slowly to 250 mg tds over a period of six weeks or so (2); despite the very slow titration patients may complain of sedation as a side effect

    • alternatives to primidone include (2,3):
      • topiramate
        • initial dose of 50 mg (2 divided doses) per day and then increasing to maintenance dose of 50 mg to 325 mg/day (2 divided doses) (3)
      • gabapentin
        • initial dose 50 mg (1 dose, increase as necessary and tolerated) to maintenance dose of 50 mg to 1800 mg/day (1 to 3 divided doses) (3)
      • pregabalin
        • intial dose 25 mg (1 dose and gradual increase as necessary) to maintenance dose of 50 mg to 600 mg/day (2 divided doses) (3)
      • busiprone
      • clonazepam
        • 0.25 mg (1 dose) (preferred use is for occasional control of tremor)
        • maintenance dose is usually 0.5 mg to 6 mg/day (1 to 3 divided doses)
        • note that this may be habituating

Treatment should be trialled for at least 8 weeks at maximally tolerated dose before moving onto the next choice (4).

Reference:

  1. Sharon Smaga. Tremor. Am Fam Physician 2003;68:1545-52,1553
  2. Clinical Evidence concise (December 2003).
  3. Rajput AH, Rajput A. Medical treatment of essential tremor.J Cent Nerv Syst Dis. 2014 Apr 21;6:29-39.
  4. Pulse (2003), 63 (49), 72.
  5. Mid Essex CCG (July 2013). Guideline for the treatment of essential tremor.

Last reviewed 01/2018

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