Practice Parameter: Therapies for essential tremor [RETIRED]: Report of the Quality Standards Subcommittee of the American Academy of Neurology
Open accessAbstract
BACKGROUND: Essential tremor (ET) is one of the most common tremor disorders in adults and is characterized by kinetic and postural tremor. To develop this practice parameter, the authors reviewed available evidence regarding initiation of pharmacologic and surgical therapies, duration of their effect, their relative benefits and risks, and the strength of evidence supporting their use. METHODS: A literature review using MEDLINE, EMBASE, Science Citation Index, and CINAHL was performed to identify clinical trials in patients with ET published between 1966 and August 2004. Articles were classified according to a four-tiered level of evidence scheme and recommendations were based on the level of evidence. RESULTS AND CONCLUSIONS: Propranolol and primidone reduce limb tremor (Level A). Alprazolam, atenolol, gabapentin (monotherapy), sotalol, and topiramate are probably effective in reducing limb tremor (Level B). Limited studies suggest that propranolol reduces head tremor (Level B). Clonazepam, clozapine, nadolol, and nimodipine possibly reduce limb tremor (Level C). Botulinum toxin A may reduce hand tremor but is associated with dose-dependent hand weakness (Level C). Botulinum toxin A may reduce head tremor (Level C) and voice tremor (Level C), but breathiness, hoarseness, and swallowing difficulties may occur in the treatment of voice tremor. Chronic deep brain stimulation (DBS) (Level C) and thalamotomy (Level C) are highly efficacious in reducing tremor. Each procedure carries a small risk of major complications. Some adverse events from DBS may resolve with time or with adjustment of stimulator settings. There is insufficient evidence regarding the surgical treatment of head and voice tremor and the use of gamma knife thalamotomy (Level U). Additional prospective, double-blind, placebo-controlled trials are needed to better determine the efficacy and side effects of pharmacologic and surgical treatments of ET.
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About 70-90% of DBS patients experience reduction of tremor that can range from 60 to 90%.
“About 70–90% of DBS patients experience reduction of tremor that can range from 60 to 90% [8, 13].”
From Controlling a motorized orthosis to follow elbow volitional movement: tests with individuals with pathological tremor (2019) · cites this paper as [13]
The Conclusions section reports 60–90% mean improvement on clinical rating scales after unilateral DBS for limb tremor. It separately reports improvement in head tremor in 71% and 90% of patients in two studies. Those figures concern different tremor types and studies, so the paper does not establish that 70–90% of DBS patients each experience a 60–90% reduction. (LLM, conf=0.87)
Experimental — accuracy not yet measuredSurgery, deep brain stimulation, and focused ultrasound tend to lose effectiveness with time and are invasive procedures that cause nonreversible brain lesions.
“However, they tend to lose effectiveness with time and are invasive procedures that cause nonreversible brain lesions (27).”
From A Review on Wearable Technologies for Tremor Suppression (2021) · cites this paper as [27]
The Conclusions describe DBS as using an implanted electrode and discuss surgical complications, supporting the description of it as invasive. But they state that postmortem examinations found no permanent anatomical changes from DBS other than the electrode tract, contrary to the claim that it causes a nonreversible brain lesion. The paper does not discuss focused ultrasound or establish that these procedures generally lose effectiveness over time. (LLM, conf=0.85)
Experimental — accuracy not yet measuredIn essential tremor, propranolol or primidone is first-line therapy and reduces hand tremor by 50% during clinical tests.
“In ET, propranolol or primidone is the first-line therapy against tremor, reducing hand tremor by 50% during clinical tests (27, 28).”
From A Review on Wearable Technologies for Tremor Suppression (2021) · cites this paper as [27]
The Recommendations section (page not specified in our copy) says either primidone or propranolol may be used as initial therapy for limb tremor in essential tremor. It does not report a 50% reduction in hand tremor with either drug; the approximately 50% figure in the Propranolol (head tremor) section concerns head tremor measured by accelerometry. (LLM, conf=0.88)
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References 124 · Cited by 371
Research works printed but not linked: 7
- Galvez-Jimenez N, Hargreave M. Topiramate and essential tremor. Ann Neurol 2000;47:837-838. Class IV.
- American Psychiatric Association Task Force. Benzodiazepines: depen- dence, toxicity, and abuse. Washington, DC: American Psychiatric Press, 1990.
- Ceravolo R, Salvetti S, Piccini P, et al. Acute and chronic effects of clozapine in essential tremor. Mov Disord 1999;14:468 -472. Class II.
- Koller WC. Tradozone in essential tremor. Clin Neuropharmacol 1989; 12:134 -137. Class I.
- Ondo W, Hunter C, Vuong KD, et al. Gabapentin for essential tremor: a multiple-dose, double-blind, placebo-controlled trial. Mov Disord 2000; 15:678 -682. Class II.
- Van Der Vet APH, Kreukniet J, Drost RH, et al. Lung function im- provement, tremor measurements and c-AMP determinations in a group of ten patients with asthmatic bronchitis after one week sus- tained release theophylline medications compared to one week placebo. Int J Clin Pharmacol Ther Toxicol 1986;24:638 -642.
- Pahwa R, Lyons KE, Wilkinson SB, et al. Comparison of thalamotomy to deep brain stimulation of the thalamus in essential tremor. Mov Disord 2001;16:140 -143. Class IV.
- Authors
- Zesiewicz, T. A., Elble, R., Louis, E. D., Hauser, R. A., Sullivan, K. L., Dewey, R. B., Ondo, W. G., Gronseth, G. S., & Weiner, W. J.
- Affiliations
- University of Maryland, Baltimore (US)
- ORCID
- Venue
- Neurology
- Published
- 2005-06-28
- Volume
- 64
- Issue
- 12
- Pages
- 2008-2020
- ISSN
- 0028-3878 (ISSN-L)
- 1526-632X
- OpenAlex
- W2143136440
- Cited by
- 371
- References
- 124
- Citations by year
- 2026: 5 · 2025: 11 · 2024: 14 · 2023: 14 · 2022: 12 · 2021: 11 · 2020: 13 · 2019: 21 · 2018: 16 · 2017: 21 · 2016: 31 · 2015: 18 · 2014: 13 · 2013: 15 · 2012: 21
- FWCI
- 13.60
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Neurology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Neurology › Neurological disorders and treatments
- Health Sciences › Medicine › Neurology › Botulinum Toxin and Related Neurological Disorders
- Social Sciences › Psychology › Clinical Psychology › Obsessive-Compulsive Spectrum Disorders
- Keywords
- essential tremor, pharmacotherapy, surgical treatment, propranolol, primidone, botulinum toxin type A, deep brain stimulation, thalamotomy, head tremor, voice tremor, limb tremor, adverse events, treatment efficacy
- MeSH terms
- Adrenergic beta-Antagonists, Anticonvulsants, Clinical Trials as Topic, Humans, Neuromuscular Agents, Thalamus, Radiosurgery, Treatment Outcome, Neurosurgical Procedures, Essential Tremor, Deep Brain Stimulation
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