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| Tremor |
 | Tremor is an involuntary, rhythmic, oscillating movement of any body part caused by contractions of
reciprocally innervated antagonist muscles. |
|
| Physiologic Tremor |
| Present in all individuals |
| Exaggerated Physiologic Tremor can be seen related
to:
 | Mental state: anxiety, stress, sleep
deprivation |
| Metabolic: fever, thyrotoxicosis |
| Drugs:
 | beta-adrenergic agonists:
Phenylpropanolamine,
Pseudoephedrine |
| Fluoxetine (Prozac),
Haloperidol (Haldol), Lithium, Methylphenidate (Ritalin),
Metoclopramide (Reglan), |
| Theophylline, Valproic acid |
|
| Diet: caffeine |
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| Essential Tremor |
| Kinetic tremor greater than resting tremor |
| May affect: hands, head, voice, legs |
| Treatment:
| Alcohol: with time, larger amount may be
needed. Judicious use of small amount before meals may be
reasonable. |
| Primidone (Mysoline):
| More effective than Propranolol. |
| Dose: Usual effective dose
250 mg hs |
| Metabolized to
| PEMA - half life 30 hours |
| phenobarbital - half life
10 days |
|
| No correlation between serum
phenobarbital level and response. |
| Phenobarbital by itself does
not help tremor |
|
| Beta Blocker:
| Propranolol (Inderal): Sustained release
recommended.
| Optimal dose 240-320
mg/d. Dose above 320 mg per day, no additional benefit.
|
| Reduce tremor amplitude. |
| 50-70% will have symptomatic relief. |
|
| Metoprolol: more Beta1. 100-200 mg/day. |
| Nadolol: 24 hr half life. 120-240 mg/day. |
| Atenolol, Pindolol not effective. |
| Arotinolol, 30 mg/day. A peripheral acting
beta blocker, significantly reduce tremor in some patients. |
|
|
| Gabapentin (Neurontin): 100-2400 mg/d,
may be useful |
| Benzodiazepines:
| Limited efficacy in tremor |
| Clonazepam (Klonopin) 0.25-4 mg/d may be effective in kinetic predominant tremor and orthostatic truncal
tremor. |
|
| Topiramate (Topamax):
| enhances GABA and inhibits carbonic anhydrase. |
| Conner reported 11 patients in an open-label
trial with reduction of both hand and head tremor. |
|
| Botulinum toxin: help voice and
head tremor |
| Surgical: Thalamotomy, Thalamic stimulation |
|
| Cerebellar Outflow Tremor |
| Slow, action-induced tremor |
| May be associated with: scanning speech,
dysarthria, nystagmus |
| Treatment:
| Benzodiazepines: Clonazepam (Klonopin) 0.25-4 mg/d |
| Isoniazide 400-1200 mg/d given with pyridoxine |
| Botulinum toxin |
| Surgical: Thalamotomy, Thalamic stimulation |
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| Orthostatic Tremor |
| Tremor of the legs > trunk or arms |
| Tremor occurs when standing, Improves with sitting or walking |
| Very fast, 16-18 Hz |
| Treatment:
| Beta Blockers: Propranolol (Inderal) 10-320 mg/d |
| Gabapentin (Neurontin) 100-2400 mg/d |
| Benzodiazepines: Clonazepam (Klonopin) 0.25-4 mg/d |
| Valproic Acid (Depakote) |
|
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| Resting tremor |
| Resting tremor, alleviated by movement, commonly
seen in Parkinsonism. |
| Commonly referred to as pill rolling tremor of the
hands, can also affect the head, trunk, jaw and lips. |
| Usually associated
with other symptoms such as bradykinesia, rigidity, postural instability. |
| See Parkinsonism page |
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| Further reading |
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Return to Movement disorder directory
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