DEAR MAYO CLINIC: My father-in-law, husband and daughter all have essential tremor. My husband has never needed treatment, since the tremor is quite mild. But my daughter was just diagnosed at 41, and her symptoms seem to really bother her. What are the treatment options for essential tremor?
ANSWER: Essential tremor is among the most common of all movement disorders. Mild essential tremor usually does not require treatment. But if the tremor becomes worse or if it interferes with a person’s daily activities, treatment may be helpful. Medications can often keep essential tremor under control. Rarely, surgery may be used to treat severe cases.
By definition, tremor causes involuntary, rhythmic shaking. Essential tremor most often affects the hands, but may also involve the head or voice. The hand tremor typically is most obvious when a person is holding his or her hands outstretched or when using the hands for fine motor skills, such as writing. Essential tremor gradually worsens — but very slowly — over many years.
The cause of essential tremor is not known. As in the situation you describe, people who have essential tremor often have a family member with the disorder, too. That seems to indicate genetics plays a role.
When essential tremor becomes bothersome, medications often help. The first line of treatment usually involves drugs called beta-blockers, notably propranolol or nadolol. They tend to be particularly useful in treating mild hand tremors. It is worth noting that these medications are different from the usual beta blockers currently used to treat high blood pressure, such as atenolol and metoprolol. Those kinds of beta blockers are not very effective for essential tremor.
Alternative medications may also be helpful, but one should be mindful of side effects with these other drugs. These include the barbiturate primidone, as well as a class of drugs known as carbonic anhydrase inhibitors, including topiramate.
Essential tremor that affects the head or voice generally does not respond as well to these medications. Head or voice tremor may, however, benefit from botulinum toxin (Botox) injections. Botox temporarily weakens the targeted muscles, reducing the tremor amplitude.
For those with long-standing and severe tremor, especially hand tremor, deep brain stimulation (DBS) may be considered. This involves implantation of a stimulating electrode into the brain, and specifically targeting the region of a brain tremor circuit within the thalamus. A pacemaker-like stimulus generator, implanted under the skin, is connected via an imperceptible wire to the electrode, turning off the tremor circuit. This impulse generator is much like a heart pacemaker. This surgery is not without risk, but typically is very efficacious.
Your daughter may wish to talk with her doctor about her tremor. He or she can review your daughter’s medical history and current medications, as well as her symptoms, to help her decide how to best manage her essential tremor. Consultation with a neurologist, especially one who specializes in tremor and other movement disorders, may be useful.
Your daughter also may find it helpful to access the resources available through the patient support group International Essential Tremor Foundation. You can find this group online at www.essentialtremor.org. — J. Eric Ahlskog, M.D., Ph.D., Neurology, Mayo Clinic, Rochester, Minn.