Treating essential tremor

Treatment for essential tremor aims to reduce or remove the involuntary movements as much as possible.

If your tremor is mild and doesn't stop you from carrying out normal activities, your condition may simply be monitored.Try toavoid things that maymake your tremor worse, such as:

• caffeine; found in coffee, tea and some fizzy drinks
• Insomnia
• stress

Speak to yourGP if you're taking medicine which could be causing a tremor. You should only stop taking prescribed medication if your doctor specifically advises you to.

Medication

If your tremor is more severe, your doctor may prescribe medication to reduce your symptoms. The most effective medicines are propranolol and primidone. Between half and three quarters of people find these medicines reduce their tremor.

Propranolol

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
• dizziness
• cold extremities
• impotence
• worsening of pre-existing asthma or heart failure

Anticonvulsants

Primidone is an anticonvulsant, usedto treat epilepsy , which also seems to help reduce essential tremor. Possible side effects include low blood pressure, drowsiness and feeling sick.

Another anticonvulsant, called topiramate, may also sometimes be used. If these medicines don't work on their own, a combination of propranolol and an anticonvulsant may be recommended.

Sedatives

If combining the above medicines doesn't work, there's some evidence that sedatives such as clonazepam and alprazolam can help. These may improve your tremor because they reduce anxiety, which can often make thetremor worse. However, sedatives can cause drowsiness and there's a risk you may become dependent on them.

Botulinum toxin

In rare cases, if the medicines described aboveprove 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's clinically safe when used in minute doses. It's sometimes used to treat dystonic tremor rather than essential tremor. Dystonic tremor isa different type of tremorwhich causesinvoluntary muscle spasms and contractions (tightening).

Surgery for severe tremor

Sometimes theessential tremor may be so severe it significantly interferes with normal activity and doesn't respond to medication. In these rare cases, surgery may be considered. There are two types of surgery:

• deep brain stimulation
• thalamotomy

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're unconscious, though you are woken upduring the procedure tomake surethe 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 to help regulate your brainwaves and control your tremor.

The National Institute for Health and Care Excellence (NICE) published guidelines on deep brain stimulation for tremor in 2006. NICE concluded the treatment is effective in improving tremor, but more information is needed about how successful it is in the long-term. Other research has found 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
• tingling
• bleeding in the brain
• fluid in the brain
• stroke , a serious medical conditioncaused bythe blood supply to part of the brainbeing cut off
• complications of general anaesthetic, such as nerve damage andnumbness

Discuss these risks with your surgeon before deciding whether to have the procedure.

In the research 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.

Thalamotomy

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
• infection
• paralysis

Getting help

If you're affected by essential tremor, you can call the National Tremor Foundation (NTF) for help and support. Their telephone number is 01708 386399. You can also visit the NTF website for further information and advice.