β-blockers
| Propranolol
| 10–40 mg, 3 times daily 120–160 mg LA daily Range: 60–320 mg/d | 10 40 |
|
| Metoprolol
| 50–100 mg twice daily 100 mg SR daily | 15 |
-
SE: wheezing, headache, dizziness, drowsiness, and insomnia; decreased HR and BP -
Lower amplitude not frequency of tremors -
Stronger evidence for propranolol, a nonselective β-blocker
|
Anticonvulsants |
| Primidone
| 62.5 mg at bedtime (increase by 62.5 mg every 7 d) | 10 |
-
SE: vertigo, ataxia, unstable gait, drowsiness, headache, polyuria, and rash; start with low dose
|
| | 125–250 mg 3 times daily Range: ≤ 250–1000 mg/d | 10–12 |
|
| Topiramate
| 100–200 mg twice daily (Start: 25 mg twice daily to limit SE) | 100–150 |
-
Effective in trials but high dropout rates and poor tolerance10,11 -
SE: dizziness, unstable gait, drowsiness, decreased weight, paresthesia, confusion, and difficulty with word finding
|
| Gabapentin
| 400–600 mg 3 times daily (Start: 100–200 mg to limit SE) | 66–115 |
-
Limited trials; efficacy inconsistent12–14 -
SE: sedation, dizziness, fatigue, drowsiness, and decreased libido; abuse potential15
|
Benzodiazepines
| Clonazepam
| 0.25–0.5 mg 3 times daily (up to 6 mg/d but increases sedation) | 16 |
|
| Alprazolam
| 0.25–0.5 mg 3 times daily (average 0.75 mg/d) | 16 |
-
SE: tolerance, falls, dependence, daytime sedation, and abuse potential
|
Other options | Amantadine, atenolol, botulinum toxin A, clonidine, clozapine, flunarizine, levetiracetam,16 methazolamide, phenobarbital, pregabalin,17 sotalol | Varies | Varies | None |