Essential Tremor

Treatment

AAN 2011 guidelines

Pharmacological management

Recommendations for use	Treatment
Level A – should be offered to patients who desire treatment for limb tremor in ET, depending on concurrent medical conditions and potential side effects	Primidone Propranolol Propranolol LA
Level B – probably effective and should be considered to reduce limb tremor in ET	Alprazolam Atenolol Gabapentin (monotherapy) Sotalol Topiramate
Level B – probably effective and should be considered to reduce head tremor in ET	Propranolol
Level C – possibly effective and may be considered to reduce limb tremor associated with ET	Botulinum toxin A injection of forearm muscles Clonazepam Nadolol Nimodipine
Recommendations against use	Treatment
Level B – probably do not reduce limb tremor in ET and should not be considered for treatment of limb tremor in ET	3,4-diaminopyridine** Acetazolamide Isoniazid Levetiracetam** Pindolol Trazodone
Level C – possibly do not reduce limb tremor in ET and may not be considered for treatment of limb tremor in ET	Flunarizine** Methazolamide Mirtazapine Nifedipine Verapamil
Level U – Insufficient evidence to support or refute efficacy in treating ET	Amantadine Clonidine Clozapine** Gabapentin (adjunct therapy) Glutethimide L-tryptophan/pyridoxine Metoprolol Nicardipine Olanzapine** Oxcarbazepine Phenobarbital Pregabalin** Quetiapine Sodium oxybate (in ethanol-sensitive ET) Theophylline Tiagabine Zonisamide**

**The conclusion and recommendation are new or different from those in the previous guideline.

Surgical conclusions and recommendations

Recommendations for use	Treatment
Level C – effectively treats contralateral limb tremor in ET that is refractory to medication management	Unilateral thalamotomy DBS of the VIM of the thalamus^23–27
Level U – insufficient evidence to support or refute efficacy in treating ET	Superiority of DBS or thalamotomy for the treatment of ET Relative advantages and disadvantages of unilateral vs bilateral DBS in the treatment of limb tremor Direct subthalamic stimulation and/or zona incerta/prelemniscal stimulation Gamma knife thalamotomy

DBS = deep brain stimulation, VIM = ventral intermediate nucleus.

Propranolol

• 60-320mg/day (average dose in trial 185mg/day)

• Reduced tremor by 50% clinically

• Long acting preparation appeared to have similar efficacy.

Primidone

• Up to 750mg/day

• Average dose 480mg/day

• Slow titration up from 25mg daily

• Significant SE - sedation, drowsiness, fatigue, depression, nausea, vomiting, ataxia etc.