Their families treatments for essential tremor

AAN Guideline Summary for

PATIENTS 

and

THEIR FAMILIES

TREATMENTS FOR ESSENTIAL TREMOR

If your doctor tells you that you have essential tremor, this fact sheet will help you talk about the treatments that may help. 

Neurologists from the American Academy of Neurology (AAN) are doctors who treat diseases of the brain and central nervous

system. They believe you should know about the safe and effective treatments for essential tremor. These treatments can

improve your quality of life, but they do have side effects.

Neurologists reviewed all of the studies for treatment of essential tremor. They made suggestions that will help doctors treat

people with essential tremor more successfully. In some cases, they found there is not enough information to decide

whether a treatment works and is safe. In some cases, they found there are treatments that should not be used for tremor.

What is essential tremor? 

Essential tremor is a common neurological disorder. It is

caused by a poorly understood disturbance of brain function.

People with essential tremor experience shaking they

cannot control. 

Essential tremor can affect: 

• The limbs, causing tremor in the hands and arms

• The head

• The vocal cords, making the voice sound shaky 

Essential tremor occurs when the muscles are used. Unlike

Parkinson tremor, essential tremor is usually not present

when the limbs are relaxed.

Tremor often begins in early adulthood. It may become

more noticeable as people get older. Since tremor occurs

during movement—such as while writing or eating—people

may find it bothersome and embarrassing.

What are the treatments for essential tremor?

There is no cure for essential tremor, but there are treatments

that give relief and improve quality of life. These include

drug therapies and surgical procedures. The treatment

chosen will depend on the severity of tremor and the 

side effects of each treatment. 

DRUG THERAPY

If the tremor interferes with your work or other daily activities,

drugs may help. Neurologists looked at data for several drugs.

Many people with tremor benefit from drug therapy. 

A decision to use drugs will depend on other medical

conditions you have and potential side effects. Your doctor

should discuss any serious side effects with you.

Limb tremor

If you have tremor in your hands and arms, there is strong*

evidence supporting the use of propranolol, primidone, or

long acting propranolol. These drugs should be offered to

people with hand and arm tremor. If taking one of these

drugs alone does not sufficiently reduce your tremor, your

doctor may prescribe a combination of drugs. Your doctor

will monitor how well these drugs are working; your dosage

may need to be adjusted.

There is also good* evidence that the following medications

are probably effective and may be helpful. They should be

considered when propranolol and primidone are not adequate:

• Sotalol and atenolol—these drugs are typically used to

regulate blood pressure; however they can be used as

substitutes to propranolol and primidone.

• Gabapentin and topiramate—these drugs are typically

used to treat seizures.

• Alprazolam—this drug is typically used to slow down

the nervous system. This medication may be habit-

forming or have other serious side effects and should 

be taken with caution. 

Botulinum toxin A injections are possibly* effective for limb

tremor, but may cause non-permanent weakness of the limb

muscles. They may be considered for hard-to-manage tremor

of the hand and arm. 

Neurologists found that there are several drugs not 

recommended for treating essential tremor. There are also

some drugs where there was not enough data to make a

decision about their effectiveness and safety. If you have

questions, discuss these drugs with your doctor. 

This is an evidence-based educational service of the American Academy of Neurology. It is designed to provide members with evidence-based

guideline recommendations to assist with decision-making in patient care. It is based on an assessment of current scientific and clinical information,

and is not intended to exclude any reasonable alternative methodologies. The AAN recognizes that specific patient care decisions are the prerogative

of the patient and the physician caring for the patient, based on the circumstances involved. Physicians are encouraged to carefully review the

full AAN guidelines so they understand all recommendations associated with care of these patients.

*After the experts review all of the studies, they describe how strong or weak the data are. 

Strong evidence = research studies with high-quality data collection, this shows that the treatment is either effective, ineffective, or harmful. 

Good evidence = data collection using a combination of high-and low-quality methods, this shows that the treatment is probably either effective,

ineffective, or harmful. 

Moderate evidence = research studies with low-quality data collection, this shows that the treatment is possibly either effective, ineffective, or harmful.

Head tremor or voice tremor

If you have head tremor, there is good* evidence 

supporting the use of propranolol. 

Moderate* evidence shows that botulinum toxin A 

injections are possibly effective and may be considered

for hard-to-manage head tremor and voice tremor. 

SURGICAL THERAPY

If your tremor is severely disabling and drugs do not relieve

your symptoms, surgery may be an option. Two types of

surgery are used to treat essential tremor. They are deep

brain stimulation (DBS) and thalamotomy. Both treatments

affect the thalamus. This is a cluster of nerve cells deep in

the brain.

Your doctor should discuss potential side effects of these

treatments with you. The decision to use these procedures

depends on your condition and the risk for complications

compared to potential successful outcomes.

Deep brain stimulation (DBS)

In DBS, an electric probe (electrode) is placed in the thalamus.

A wire from the electrode is routed beneath the skin to 

a pacemaker device implanted near your collarbone. The

pacemaker and electrode stimulate the thalamus with

pulses of electricity. This blocks the brain activity that causes

tremor. Only special centers perform this procedure. 

Evidence shows that DBS is effective and may used to treat

people who experience hard-to-manage limb tremor. The

experts did not find enough data to make recommendations

for the use of DBS to treat head or voice tremor. DBS has

fewer side effects than thalamotomy.

Thalamotomy

During this surgery, a lesion is placed on a small part of

the thalamus. This interferes with the abnormal brain activity

that causes the tremor. This is typically done on only one

side of the brain. 

Evidence shows that thalamotomy surgery on one side of

the brain may be effective and used to treat a limb tremor

that cannot be controlled by medication. Thalamotomy

on both sides of the brain is not recommended because

of high risk of disabling side effects. 

Readers should be aware that it is difficult to study surgical

therapies in the same way as other medical therapies. It is

difficult to design a study where neither the physician nor

the patient knows if the patient went through the real surgical

procedure or a comparison (sham) procedure. Therefore,

the evidence that DBS or thalamotomy successfully treats

limb tremor is weakened by the research methods involved. 

Gamma knife surgery

Because there was not enough data available, the panel

could not make recommendations for the use of a non-

invasive procedure called gamma knife thalamotomy,

which uses radiation. 

Talk to your neurologist

It is best to see a doctor who has experience with tremor

and movement disorders for diagnosis. You should have

a thorough evaluation by a neurologist. He or she will exam-

ine the parts of your body that are shaking and determine

if essential tremor or some another condition is the cause.

Not every treatment works for every patient. Your doctor

will recommend an individualized treatment plan, including

lifestyle changes that may reduce your tremor. A treatment

decision will depend on other medical conditions you have

and potential side effects. Your doctor should discuss

serious side effects, if any. All treatments have some side

effects; the choice of which side effects can be tolerated

depends on the individual.

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