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What drugs help in essential tremor?

A Medical treatment for essential tremor is unsatisfactory, most patients finding the adverse effects of medication worse than the tremor.

Many patients manage their own tremor with judicious use of alcohol but some become dependent as a result. It is initially worth talking to the patient about avoiding coffee and tremorgenic drugs, and ensuring they understand the nature and purpose of a trial of treatment.

Many neurologists would suggest primidone first as an alternative to propranolol in a patient with asthma. Patients often find the first dose difficult to tolerate and I therefore suggest starting with a quarter of a 250mg tablet at night, building up very slowly to 250mg three times daily over six weeks or so.

Despite this slow titration many complain bitterly of sedation. Primidone is still readily available and almost certainly will continue to be so indefinitely despite recent attempts to withdraw it from the UK pharmacopeia.

Alternatives to primidone include phenytoin (start at 250-300mg daily), gabapentin (building up to 3600mg daily in three divided doses), topiramate (start at 25mg twice daily and build up to 200mg twice daily), buspirone 5mg three times daily and baclofen (5mg twice daily to 20mg three times daily). Clonazepam 0.5-3mg daily in divided doses is sometimes reasonably effective but habituating.

Dr Richard Grünewald is a consultant neurologist at the Royal Hallamshire Hospital, Sheffield

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