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Key Features

  • Tremor may begin at any age and is enhanced by emotional stress

  • Cause is uncertain

  • Sometimes inherited in an autosomal dominant manner

Clinical Findings

  • Postural tremor usually involves one or both hands, the head, or the hands and head, whereas the legs tend to be spared

  • Speech may also be affected if the laryngeal muscles are involved

  • Physical examination reveals no other abnormalities

  • Ingestion of a small quantity of alcohol commonly provides remarkable but short-lived relief by an unknown mechanism

  • Although the tremor may become more conspicuous with time, it generally leads to little disability, and treatment is often unnecessary

  • Occasionally, it interferes with manual skills and leads to impairment of handwriting

Treatment

  • Propranolol long-acting, either intermittently or indefinitely, 60–240 mg once daily orally

  • Primidone may be helpful, but patients are often very sensitive to it

    • Starting dose is 50 mg once daily orally

    • Daily dose is increased by 50 mg every 2 weeks depending on the response

    • Maintenance dose of 125 mg three times daily orally is commonly effective

  • Occasional patients do not respond to these measures but are helped by

    • Alprazolam (up to 3 mg daily orally in divided doses)

    • Mirtazapine (15 or 30 mg at night orally)

    • Topiramate (up to 400 mg daily orally, titrated up over 6–8 weeks)

    • Gabapentin (1800 mg daily orally in divided doses)

    • Clozapine (30–50 mg twice daily orally)

  • Other oral antiepileptic agents that are sometimes effective include levetiracetam and zonisamide

  • Disabling tremor unresponsive to medical treatment may be helped by high-frequency thalamic stimulation on one or both sides, according to laterality of symptoms

  • Focused transcranial ultrasound thalamotomy using MRI guidance is also effective

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