There is no cure for essential tremor. The aim of treatment is to reduce or remove the involuntary movements as much as possible.
If your tremor is mild and does not stop you from carrying out normal activities, your condition may simply be monitored. You should avoid things that make your tremor worse, such as:
- caffeine, found in coffee, tea and some fizzy drinks
- not getting enough sleep
If your tremor is more severe, your doctor may prescribe medication. The most effective medicines are propranolol and primidone. Between half and three quarters of people find that these medicines reduce their tremor.
Propranolol is a beta-blocker usually used to treat heart disease and high blood pressure (hypertension). It reduces tremors for a few hours after each dose. The possible side effects of taking propranolol include:
- feeling sick
- cold extremities
- worsening of pre-existing asthma or heart failure
Primidone is an anticonvulsant, also used to treat epilepsy. Possible side effects include low blood pressure, drowsiness and feeling sick.
Another anticonvulsant, called topiramate, may also sometimes be used. If these medicines do not work on their own, a combination of propranolol and an anticonvulsant may be recommended.
If combining the above medicines does not work, there is some evidence that sedatives such as clonazepam and alprazolam can help. These may improve your tremor because they reduce anxiety, which can often make the tremor worse. However, sedatives can cause drowsiness and there is a risk you may become dependent on them.
In rare cases, if the medicines described above prove to be ineffective, botulinum toxin may be used to treat essential tremor. The botulinum toxin is injected directly into the trembling muscles to block nerve transmissions and relax the muscles.
Botulinum toxin type A is a powerful poison that is clinically safe when used in minute doses. It is sometimes used to treat dystonic tremor, which is a different type of tremor that causes involuntary muscle spasms and contractions (tightening).
Sometimes the essential tremor may be so severe that it significantly interferes with normal activity and does not respond to medication. In these rare cases, surgery may be considered. There are two types of surgery:
- deep brain stimulation
These procedures are described below.
Deep brain stimulation
Deep brain stimulation involves placing one or more electrodes (small metallic needles) in an area of your brain called the thalamus. This is done under general anaesthetic so you are unconscious, though you are woken up during the procedure to make sure that the electrodes are in the correct place.
Thin wires run from the electrodes to a pulse generator (a device similar to a pacemaker), which is implanted under the skin of your chest. The generator produces an electric current that helps regulate your brainwaves and controls your tremor.
The National Institute for Health and Care Excellence (NICE) published guidelines on deep brain stimulation for tremor in 2006. NICE concluded that the treatment is effective in improving tremor, but that more information is needed regarding how successful it is in the long-term. Other research has found that deep brain stimulation can reduce tremor by around 90%.
Possible adverse effects of deep brain stimulation include:
- infection of the surgical scar site
- speech problems
- bleeding in the brain
- fluid in the brain
- stroke, a serious medical condition that occurs when the blood supply to part of the brain is cut off
- complications of general anaesthetic, such as nerve damage and numbness
Discuss these risks with your surgeon before deciding whether to have the procedure.
In the research that NICE looked at, side effects were relatively rare. More recent research has also concluded that deep brain stimulation is a relatively safe procedure. Certain side effects can be eliminated by adjusting the level of stimulation produced by the pulse generator.
A thalamotomy involves making a small hole in the thalamus, which is the same area of the brain targeted for deep brain stimulation. The procedure has been shown to be effective in improving tremor.
Deep brain stimulation is often preferred to thalamotomy because it usually causes fewer side effects and some side effects can be reversed by adjusting the stimulation parameters or abandoning stimulation altogether.
However, thalamotomy has some advantages over deep brain stimulation, such as avoiding the need for follow up appointments to check the pulse generator and replace batteries.
Side effects of a thalamotomy can include:
- confusion and problems thinking
- speech and balance problems
- bleeding in the brain