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==Medical Therapy== | ==Medical Therapy== | ||
'''Non-pharmacological Therapy''' | '''Non-pharmacological Therapy''' | ||
*These may help minimize tremor regardless of the [[cause]]. Basis of non [[pharmacological]] [[therapy]] includes: | *These may help minimize tremor regardless of the [[cause]]. Basis of non [[pharmacological]] [[therapy]] includes: | ||
**Lifestyle changes: Limiting tremor-provoking substances such as [[caffeine]] and [[medication]]. | **Lifestyle changes: Limiting tremor-provoking substances such as [[caffeine]] and [[medication]]. | ||
**[[Physical therapy]]: [[Physical]], [[speech]]-language, [[occupational therapy]]. | **[[Physical therapy]]: [[Physical]], [[speech]]-language, [[occupational therapy]]. | ||
**[[Psychological]] techniques: Relaxation techniques, [[biofeedback]]. | **[[Psychological]] techniques: Relaxation techniques, [[biofeedback]]. | ||
'''Pharmacological Therapy''' | '''Pharmacological Therapy''' | ||
*[[Essential tremor]]: | *[[Essential tremor]]: | ||
**First line [[medications]] are [[propranolol]] (40 to 240 mg/day) or [[primidone]] (initiated at 12.5 mg daily, titrated gradually to the dose of 50 and 750 mg daily - divided into [[BID]] or [[TID]])<ref name="pmid16800824">{{cite journal| author=Hess CW, Saunders-Pullman R| title=Movement disorders and alcohol misuse. | journal=Addict Biol | year= 2006 | volume= 11 | issue= 2 | pages= 117-25 | pmid=16800824 | doi=10.1111/j.1369-1600.2006.00017.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16800824 }} </ref> | **First line [[medications]] are [[propranolol]] (40 to 240 mg/day) or [[primidone]] (initiated at 12.5 mg daily, titrated gradually to the dose of 50 and 750 mg daily - divided into [[BID]] or [[TID]]). <ref name="pmid16800824">{{cite journal| author=Hess CW, Saunders-Pullman R| title=Movement disorders and alcohol misuse. | journal=Addict Biol | year= 2006 | volume= 11 | issue= 2 | pages= 117-25 | pmid=16800824 | doi=10.1111/j.1369-1600.2006.00017.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16800824 }} </ref> | ||
**Second line [[medications]] include [[gabapentin]], [[pregabalin]], [[topiramate]], [[beta-blockers]] ([[atenolol]] and [[metoprolol]]), [[benzodiazepines]] ([[clonazepam]], [[alprazolam]]). | **If not effective individually then these two [[medications]] should be tried in combination. | ||
**Third line [[medications]] include [[nimodipine]] and [[clozapine]]<ref name="pmid15972843">{{cite journal| author=Zesiewicz TA, Elble R, Louis ED, Hauser RA, Sullivan KL, Dewey RB | display-authors=etal| title=Practice parameter: therapies for essential tremor: report of the Quality Standards Subcommittee of the American Academy of Neurology. | journal=Neurology | year= 2005 | volume= 64 | issue= 12 | pages= 2008-20 | pmid=15972843 | doi=10.1212/01.WNL.0000163769.28552.CD | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15972843 }} </ref> | **Second line [[medications]] include [[gabapentin]], [[pregabalin]], [[topiramate]], [[beta-blockers]] ([[atenolol]] and [[metoprolol]]), [[benzodiazepines]] ([[clonazepam]], [[alprazolam]]). | ||
*[[Parkinson's disease]]<ref name="pmid29083328">{{cite journal| author=Jagadeesan AJ, Murugesan R, Vimala Devi S, Meera M, Madhumala G, Vishwanathan Padmaja M | display-authors=etal| title=Current trends in etiology, prognosis and therapeutic aspects of Parkinson's disease: a review. | journal=Acta Biomed | year= 2017 | volume= 88 | issue= 3 | pages= 249-262 | pmid=29083328 | doi=10.23750/abm.v88i3.6063 | pmc=6142835 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29083328 }} </ref><ref name="pmid21321834">{{cite journal| author=Puschmann A, Wszolek ZK| title=Diagnosis and treatment of common forms of tremor. | journal=Semin Neurol | year= 2011 | volume= 31 | issue= 1 | pages= 65-77 | pmid=21321834 | doi=10.1055/s-0031-1271312 | pmc=3907068 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21321834 }} </ref> | **Third line [[medications]] include [[nimodipine]] and [[clozapine|clozapine.]] <ref name="pmid15972843">{{cite journal| author=Zesiewicz TA, Elble R, Louis ED, Hauser RA, Sullivan KL, Dewey RB | display-authors=etal| title=Practice parameter: therapies for essential tremor: report of the Quality Standards Subcommittee of the American Academy of Neurology. | journal=Neurology | year= 2005 | volume= 64 | issue= 12 | pages= 2008-20 | pmid=15972843 | doi=10.1212/01.WNL.0000163769.28552.CD | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15972843 }} </ref> | ||
**First-line: [[Carbidopa]]-[[levodopa]] in combination, as [[carbidopa]] prevents conversion of [[levodopa]] into [[dopamine]] before reaching the [[brain]], hence increasing [[efficacy]]. | **[[Alcohol]] does help come [[patients]] in minimizing tremor and some [[patients]] have noticed rebound worsening after the effect of [[alcohol]] fades. <ref name="pmid20451458">{{cite journal| author=Louis ED| title=Essential tremor: evolving clinicopathological concepts in an era of intensive post-mortem enquiry. | journal=Lancet Neurol | year= 2010 | volume= 9 | issue= 6 | pages= 613-22 | pmid=20451458 | doi=10.1016/S1474-4422(10)70090-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20451458 }} </ref> | ||
*[[Parkinson's disease|Parkinson's disease:]] <ref name="pmid29083328">{{cite journal| author=Jagadeesan AJ, Murugesan R, Vimala Devi S, Meera M, Madhumala G, Vishwanathan Padmaja M | display-authors=etal| title=Current trends in etiology, prognosis and therapeutic aspects of Parkinson's disease: a review. | journal=Acta Biomed | year= 2017 | volume= 88 | issue= 3 | pages= 249-262 | pmid=29083328 | doi=10.23750/abm.v88i3.6063 | pmc=6142835 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29083328 }} </ref><ref name="pmid21321834">{{cite journal| author=Puschmann A, Wszolek ZK| title=Diagnosis and treatment of common forms of tremor. | journal=Semin Neurol | year= 2011 | volume= 31 | issue= 1 | pages= 65-77 | pmid=21321834 | doi=10.1055/s-0031-1271312 | pmc=3907068 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21321834 }} </ref> | |||
**First-line: [[Carbidopa]]-[[levodopa]] in combination, as [[carbidopa]] prevents conversion of [[levodopa]] into [[dopamine]] before reaching the [[brain]], hence increasing [[efficacy]]. | |||
**[[Dopamine]] [[agonists]]: Mimics [[dopamine]] effect on the [[brain]]. Not as effective as [[levodopa]], | **[[Dopamine]] [[agonists]]: Mimics [[dopamine]] effect on the [[brain]]. Not as effective as [[levodopa]], | ||
**[[MAO B inhibitors]]:[[Selegiline]], [[rasagiline]], [[safinamide]]. These prevent [[dopamine]] breakdown in brain by inhibiting [[monoamine oxidase B]] [[enzyme]]. | **[[MAO B inhibitors]]:[[Selegiline]], [[rasagiline]], [[safinamide]]. These prevent [[dopamine]] breakdown in brain by inhibiting [[monoamine oxidase B]] [[enzyme]]. | ||
**[[Catechol O-methyltransferase]] (COMT) inhibitors: [[Entacapone]], [[opicapone]]. Increases efficacy of [[levodopa]] by preventing metabolism. | **[[Catechol O-methyltransferase]] (COMT) inhibitors: [[Entacapone]], [[opicapone]]. Increases efficacy of [[levodopa]] by preventing metabolism. | ||
**[[Anticholinergics]]: [[Benztropine]], [[trihexyphenidyl]]. Minimizes tremor associated with [[Parkinson's disease]]. | **[[Anticholinergics]]: [[Benztropine]], [[trihexyphenidyl]]. Minimizes tremor associated with [[Parkinson's disease]]. | ||
*[[Physiologic | *[[Physiologic]] Tremor: | ||
**Factors than enhance a physiological tremor must be controlled. | **Factors than enhance a physiological tremor must be controlled. | ||
**[[Propranolol]] can be take prophylactically to prevent enhanced [[physiologic]] tremor in situations that trigger it. | **[[Propranolol]] can be take prophylactically to prevent enhanced [[physiologic]] tremor in situations that trigger it. | ||
*[[Multiple Sclerosis]]: | *[[Multiple Sclerosis]]: | ||
**[[Beta-blockers]], [[anxiolytics]], [[anticonvulsants]] can help minimize MS-related tremors. | **[[Beta-blockers]], [[anxiolytics]], [[anticonvulsants]] can help minimize MS-related tremors. | ||
*[[Orthostatic]] Tremor<ref name="pmid27713855">{{cite journal| author=Benito-León J, Domingo-Santos Á| title=Orthostatic Tremor: An Update on a Rare Entity. | journal=Tremor Other Hyperkinet Mov (N Y) | year= 2016 | volume= 6 | issue= | pages= 411 | pmid=27713855 | doi=10.7916/D81N81BT | pmc=5039949 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27713855 }} </ref> | *[[Orthostatic]] Tremor: <ref name="pmid27713855">{{cite journal| author=Benito-León J, Domingo-Santos Á| title=Orthostatic Tremor: An Update on a Rare Entity. | journal=Tremor Other Hyperkinet Mov (N Y) | year= 2016 | volume= 6 | issue= | pages= 411 | pmid=27713855 | doi=10.7916/D81N81BT | pmc=5039949 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27713855 }} </ref> | ||
**First line: [[Clonazepam]], should be started at 0.5mg and titrated up to 2mg thrice a day. | **First line: [[Clonazepam]], should be started at 0.5mg and titrated up to 2mg thrice a day. | ||
**Second line: [[Gabapentin]] (300 to 2400mg/day), [[sodium valproate]], [[carbamazepine]], [[phenobarbital]]. | **Second line: [[Gabapentin]] (300 to 2400mg/day), [[sodium valproate]], [[carbamazepine]], [[phenobarbital]]. | ||
*[[Alcohol]] [[withdrawal]] tremor: | *[[Alcohol]] [[withdrawal]] tremor: | ||
**[[Hydration]], [[folate]], [[thiamine]], [[multivitamin]], [[benzodiazepine]]<ref name="pmid8654316">{{cite journal| author=Milanov I, Toteva S, Georgiev D| title=Alcohol withdrawal tremor. | journal=Electromyogr Clin Neurophysiol | year= 1996 | volume= 36 | issue= 1 | pages= 15-20 | pmid=8654316 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8654316 }} </ref> | **[[Hydration]], [[folate]], [[thiamine]], [[multivitamin]], [[benzodiazepine]] <ref name="pmid8654316">{{cite journal| author=Milanov I, Toteva S, Georgiev D| title=Alcohol withdrawal tremor. | journal=Electromyogr Clin Neurophysiol | year= 1996 | volume= 36 | issue= 1 | pages= 15-20 | pmid=8654316 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8654316 }} </ref> | ||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
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[[Category:Neurology]] | |||
[[Category: | [[Category:Primary care]] | ||
Latest revision as of 02:10, 18 February 2021
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Zehra Malik, M.B.B.S[2]
Overview
The mainstay of treatment for tremor is to recognize the type of tremor and underlying etiology and then treat is appropriately. Tremor cannot be cured but it can be managed optimally with indicated medications and non-pharmacological therapy.
Medical Therapy
Non-pharmacological Therapy
- These may help minimize tremor regardless of the cause. Basis of non pharmacological therapy includes:
- Lifestyle changes: Limiting tremor-provoking substances such as caffeine and medication.
- Physical therapy: Physical, speech-language, occupational therapy.
- Psychological techniques: Relaxation techniques, biofeedback.
Pharmacological Therapy
- Essential tremor:
- First line medications are propranolol (40 to 240 mg/day) or primidone (initiated at 12.5 mg daily, titrated gradually to the dose of 50 and 750 mg daily - divided into BID or TID). [1]
- If not effective individually then these two medications should be tried in combination.
- Second line medications include gabapentin, pregabalin, topiramate, beta-blockers (atenolol and metoprolol), benzodiazepines (clonazepam, alprazolam).
- Third line medications include nimodipine and clozapine. [2]
- Alcohol does help come patients in minimizing tremor and some patients have noticed rebound worsening after the effect of alcohol fades. [3]
- Parkinson's disease: [4][5]
- First-line: Carbidopa-levodopa in combination, as carbidopa prevents conversion of levodopa into dopamine before reaching the brain, hence increasing efficacy.
- Dopamine agonists: Mimics dopamine effect on the brain. Not as effective as levodopa,
- MAO B inhibitors:Selegiline, rasagiline, safinamide. These prevent dopamine breakdown in brain by inhibiting monoamine oxidase B enzyme.
- Catechol O-methyltransferase (COMT) inhibitors: Entacapone, opicapone. Increases efficacy of levodopa by preventing metabolism.
- Anticholinergics: Benztropine, trihexyphenidyl. Minimizes tremor associated with Parkinson's disease.
- Physiologic Tremor:
- Factors than enhance a physiological tremor must be controlled.
- Propranolol can be take prophylactically to prevent enhanced physiologic tremor in situations that trigger it.
- Multiple Sclerosis:
- Beta-blockers, anxiolytics, anticonvulsants can help minimize MS-related tremors.
- Orthostatic Tremor: [6]
- First line: Clonazepam, should be started at 0.5mg and titrated up to 2mg thrice a day.
- Second line: Gabapentin (300 to 2400mg/day), sodium valproate, carbamazepine, phenobarbital.
- Alcohol withdrawal tremor:
References
- ↑ Hess CW, Saunders-Pullman R (2006). "Movement disorders and alcohol misuse". Addict Biol. 11 (2): 117–25. doi:10.1111/j.1369-1600.2006.00017.x. PMID 16800824.
- ↑ Zesiewicz TA, Elble R, Louis ED, Hauser RA, Sullivan KL, Dewey RB; et al. (2005). "Practice parameter: therapies for essential tremor: report of the Quality Standards Subcommittee of the American Academy of Neurology". Neurology. 64 (12): 2008–20. doi:10.1212/01.WNL.0000163769.28552.CD. PMID 15972843.
- ↑ Louis ED (2010). "Essential tremor: evolving clinicopathological concepts in an era of intensive post-mortem enquiry". Lancet Neurol. 9 (6): 613–22. doi:10.1016/S1474-4422(10)70090-9. PMID 20451458.
- ↑ Jagadeesan AJ, Murugesan R, Vimala Devi S, Meera M, Madhumala G, Vishwanathan Padmaja M; et al. (2017). "Current trends in etiology, prognosis and therapeutic aspects of Parkinson's disease: a review". Acta Biomed. 88 (3): 249–262. doi:10.23750/abm.v88i3.6063. PMC 6142835. PMID 29083328.
- ↑ Puschmann A, Wszolek ZK (2011). "Diagnosis and treatment of common forms of tremor". Semin Neurol. 31 (1): 65–77. doi:10.1055/s-0031-1271312. PMC 3907068. PMID 21321834.
- ↑ Benito-León J, Domingo-Santos Á (2016). "Orthostatic Tremor: An Update on a Rare Entity". Tremor Other Hyperkinet Mov (N Y). 6: 411. doi:10.7916/D81N81BT. PMC 5039949. PMID 27713855.
- ↑ Milanov I, Toteva S, Georgiev D (1996). "Alcohol withdrawal tremor". Electromyogr Clin Neurophysiol. 36 (1): 15–20. PMID 8654316.