The first stage of treatment is correct
diagnosis and giving appropriate information and reassurance.
Correct diagnosis is critical. For many people reassurance that their tremor
is not associated with progressive neuro-degeneration and an explanation of the
condition is all that is required – certainly at the beginning.
If the tremor is intrusive and interfering with
quality of life, in particular work and social/pleasure activities, then
medications can be considered. There is
no specific medication for ET. The two medicines
of choice are non-selective beta blockers, such as propranolol LA, or the
anticonvulsant Mysoline (primidone).
Propranolol
LA can be used on an ‘as required basis’ before the individual goes into a
situation where the tremor may become intrusive, for example prior to giving a speech
orplaying a musical instrument in public. The medication can also be used on a regular
basis. The average reduction in tremor
amplitude is up to 50% and normal exacerbations of tremor will be
prevented. However, more than 20% of
people find beta blockers unacceptable due to side effects and there are some
in whom it is absolutely contraindicated, e.g. those with asthma and related
disorders.
Mysoline is another first line medicine. It has to be introduced at very low dose, as
one in five people are exquisitely sensitive to it and has to be built up very
slowly, but in some it can be very effective.
Theoretically there is no reason why propranolol and Mysoline cannot be
used together. Use of Mysoline has been
improved with the introduction of 50 mg tablets – an average tolerated dose 125
mg three times daily. There are a number
of second line medicines which can be tried, including clonazepam, mirtazapine,
phenobarbitone, but they are often disappointing. Specific localised tremors can be helped with
botulinum toxin injections into the tremogenic muscles. This has a particular place in tremor of the
head and neck, for which the effects of other medication tend to be inadequate;
botulinum toxin can have a dramatic effect, but needs to be repeated at regular
intervals.
As with Parkinson’s and other involuntary
movements, some people who have intrusively symptomatic tremors which do not
respond well to medications can, in the absence of contraindications, be
treated with the insertion of deep brain stimulators into appropriate parts of
the brain. This is called deep brain
stimulation (DBS).
Previously, those with disabling tremors who
did not respond to medications, could be offered destructive surgical lesions
in parts of the brain, such as thalamotomy. With the introduction of deep brain
stimulation, which is generally considered preferable, such stereotactic
procedures are relatively rarely carried out now.
Complementary therapies to promote
relaxation and reduce of stress can be very valuable in managing ET. Psychological inputs, including cognitive behavioural therapy,
relaxation therapies, meditation,
neuro-behavioural training and
neuro-linguistic programming all have parts to play in the management of some
individuals. Likewise, nutritional advice may be
important.
