Can surgery treat essential tremor?
Surgery should be considered for patients with disabling tremor that is not adequately controlled with drug therapy.
The proven surgical treatments are:
- MR-guided focused ultrasound.
- Chronic thalamic deep brain stimulation (DBS).
- Stereotactic thalamotomy.
Patients who cannot undergo surgery include those who have medical conditions other than essential tremor (ET) that make them poor surgical candidates and those with a significant loss of thinking ability.
Surgical procedures allow patients to potentially reduce their tremor medicines.
When are drugs prescribed to treat essential tremor (ET)?
When essential tremor (ET) often prevents with daily activities, long-term drug treatment is needed. Your healthcare provider will determine which treatment is best based on other medical conditions you may have and based on the safety of the drugs. The goal is to minimize the side effects of drugs while having improvement in function.
With the use of medication, patients may see improvement in the ability to control tremor and improvement in functions like drinking from a cup or using food utensils. More specialized motor functions, such as being able to thread a needle, may not improve.
For patients with mild ET, the effects of the condition can be lessened by the patient’s minimizing exposure to emotional stress and avoiding substances, such as caffeine and nicotine that may increase tremor. In social situations, a person with mild tremor can take a beta blocker drug (see below) or drink a small amount of alcohol if such treatments are approved by a doctor.
Drugs most commonly used to treat ET include beta blocking drugs Inderal® (propranolol), Tenormin® (atenolol), Betapace® (sotalol), and Lopressor® (metoprolol).
The beta blocker Inderal has been used to treat ET for more than 40 years. It is not clear how Inderal reduces tremors, but the drug may work by blocking nerve impulses to the muscles. Approximately 50 to 60% of patients experience some improvement in functional disability, but total tremor suppression usually is not achieved. The greatest improvement is in hand tremors and voice tremor. The drugs may be taken once a day (for a longer-acting formulation) or twice a day depending upon the formulation used.
Beta blockers are not right for everyone. Side effects may include:
- Slowing heart rate
- Erectile dysfunction
Some of these side effects may require that the treatment be stopped.
Be sure to tell your doctor if you:
- Have asthma or other bronchial conditions; beta blockers may cause asthma symptoms
- Have coronary artery disease or certain heart arrhythmias
- Have kidney disease
- Have liver disease
- Have diabetes
- Are pregnant or nursing
Facts about drugs
Inderal (propranolol): While you are taking the beta blocker Inderal, your healthcare provider will monitor your heart rate and blood pressure regularly. If you have no significant side effects, you can ask for the longer-acting version. In general, Inderal works over a long period of time to suppress tremors; however, about 10% of people will develop tolerance to the drug after a year. This means that the drug stops being effective in the patient when given in the same dose as when the patient began treatment.
Mysoline® (primidone): Mysoline is an anti-seizure drug that is also effective for treating essential tremor. It is not clear how it works. Mysoline appears to be as effective as Inderal, with significant suppression of tremor in most patients. This medication is most useful for those with hand tremor. The duration of effect from one dose is 24 hours. As with Inderal, a percentage of people may develop tolerance to the treatment after a year.
In most cases, Mysoline is given to patients who do not tolerate propranolol. Mysoline also can be given in addition to Inderal to improve symptomatic relief. Some side effects of Mysoline may occur in the short term (within the first few days of starting treatment); however, these side effects lessen with longer use. Mysoline may cause:
- Difficulty walking
Serious complications with the drug are rare and include blood cell and bone marrow problems. Your healthcare provider will check your blood counts every 6-12 months to screen for these problems. Mysoline has a drug interaction with phenobarbital, so use caution if the drugs are taken together.
Before taking Mysoline, be sure to tell your doctor if you:
- Are pregnant or nursing
- Are taking oral contraceptives (brand names include Ortho-Novum® and Triphasil®) that contain the hormone estrogen
- Have kidney or liver problems
- Are taking blood-thinning drugs ( Coumadin®, Panwarfin®, doxycycline, corticosteroids and Griseofulvin®)
In addition, you should avoid alcoholic beverages while taking Mysoline. Do not stop taking the drug suddenly or switch brands without first consulting your healthcare provider.
Neurontin® (gabapentin): Experts use Neurontin for short-term treatment of ET affecting the hands, but it is not known how the drug works. In most cases, it is not used in conjunction with other drugs.
Side effects are rare but include:
- Walking difficulties
- Weight gain
Alcohol: Some people with ET report symptom relief after drinking a glass of wine or a cocktail. The effect usually lasts about an hour, but rebound tremors occur after this time. It is generally not recommended that you attempt to treat ET symptoms with alcohol.
Benzodiazepines: Benzodiazepines (brand names Xanax®, Klonopin®, Valium®, and Ativan®) may help patients whose ET is not improved by other drugs. These medications appear to relieve tremors associated with emotional stress or anxiety. Side effects of benzodiazepines include confusion, memory loss, and sedation.
Botulinum Toxin: Botox® (subtype A) and Myobloc® (subtype B) are the brand names for botulinum toxin, which can be used to treat some movement problems. The drugs work by paralyzing muscles to reduce tremor. In experienced hands, the drug also can be used to treat voice or head tremors. This treatment consists of an injection into muscle tissue once every three months. Do not take this drug if you are pregnant or if you have myasthenia gravis, post-polio syndrome, or Eaton-Lambert syndrome. Side effects are rare but may include muscle weakness or loss of appetite.
Are there alternative therapies for essential tremor?
Currently, there is no evidence that alternative therapies are beneficial in treating ET. Patients who have tremors that worsen with emotional stress may find relaxation therapies helpful. However, this type of alternative therapy is not a treatment. Some herbal supplements may make tremor worse. Always consult your doctor before trying any alternative therapy.
Can essential tremor be cured?
There is no cure for ET, but treatments that provide relief from its symptoms may be helpful in improving quality of life. These include medications that ease tremor. Not every treatment or procedure is effective for every person with ET. Your doctor will recommend an individualized treatment plan, including certain lifestyle changes that may help to reduce your tremors.