Table 1.

Drug treatment options for ET

CLASS AND ROLE	DRUG	DOSE (ORAL) IN ET	COST/MO, $	COMMENTS
β-blockers First-line treatment in moderate to severe limb ET; might be helpful for head tremor6	Propranolol Inderal, generic	10–40 mg, 3 times daily 120–160 mg LA daily Range: 60–320 mg/d	10 40	CI: asthma, uncompensated heart failure, low HR (<50 BPM), low BP (< 90 mm Hg)7
	Metoprolol Lopresor, generic	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 is a first-line option in moderate to severe limb ET, especially	Primidone Mysoline, generic	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
for those who cannot tolerate β-blockers (primidone more effective than phenobarbital)8,9		125–250 mg 3 times daily Range: ≤ 250–1000 mg/d	10–12	Combination propranolol and primidone occasionally useful
Others second-line	Topiramate Topamax, generic	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 Neurontin, generic	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 Intermittent use for stressful situations that make tremor worse	Clonazepam Rivotril, generic	0.25–0.5 mg 3 times daily (up to 6 mg/d but increases sedation)	16	Limited benefit for tremor, but has hypnotic effect and might help decrease anxiety
	Alprazolam Xanax, generic	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

BP—blood pressure, BPM—beats per minute, CI—contraindications, ET—essential tremor, HR—heart rate, LA—long acting, SE—side effects, SR—sustained release.
Data from Jensen and Regier4 and Lyons and Pahwa.5