Certain patients with mild tremor may only need tremor control for short, specific periods of time (for example, while giving a speech or going to dinner with friends). In such cases, propranolol (10–20 mg, immediate-release form) can be used as needed; if ineffective or causing side effects, alprazolam 0.25–1 mg can be tried. Daily medication may be required when as-needed medication fails.

Propranolol (extended release 80–160 mg daily) and primidone (typically 50–250 mg daily) are first-line agents for the management of essential tremor. Both have demonstrated efficacy in clinical trials. Agent selection depends largely on the patient’s preference and comorbidities. For patients with diabetes, asthma, or cardiac disease, primidone may be preferred. However, primidone can be sedating and may not be ideal for younger, employed patients; it also increases the risk of osteoporosis with long-term use. When no relevant comorbidities are present, propranolol is preferred due to its more favorable side-effect profile.

When first-line agents do not provide sufficient tremor control or are poorly tolerated, second-line agents can be considered either as monotherapy or as adjunctive agents. Benzodiazepines, including clonazepam and alprazolam, have been shown to be effective, but can cause sedation and carry the potential for abuse. Clonazepam (0.5–2 mg twice daily) is generally preferred given its longer duration of action. If benzodiazepines are unsuccessful, then topiramate (25–100 mg twice daily) can be tried. Side effects include cognitive slowing, weight loss, paresthesias, and, in certain populations, an increased rate of nephrolithiasis. Gabapentin may also be considered, though efficacy in clinical trials has been mixed. Finally, the β-blockers atenolol or sotalol can be considered as alternatives to propranolol, but have not been well studied.

While medical management is effective in some patients, approximately one-third of them discontinue medications due to either side effects or lack of efficacy. If a patient has failed first- and second-line agents, or has contraindications to their use but is not willing to consider surgical management, botulinum toxin injections can be considered. These can be effective in dampening head, voice, and limb tremors, but injections need to be repeated quarterly and rarely provide complete tremor remission.

Deep brain stimulation (DBS) is a neurosurgical procedure in which electrodes are implanted in the brain and connected to programmable pulse generators that are implanted subcutaneously. For essential tremor, the electrodes are placed in the ventral intermediate nucleus of the thalamus. DBS is a well-established, efficacious treatment option for ET that significantly improves quality of life. For patients with bilateral tremor who are cognitively intact, bilateral DBS is suggested. For patients with dementia or mild cognitive impairment, unilateral lead implantation is preferred, to decrease the possibility of worsening cognition.

Magnetic resonance–guided focused ultrasound (FUS) is a noninvasive procedure in which ultrasound beams are arranged to converge on a specific target within the brain, causing the tissue to heat until a permanent lesion is generated. Currently, FUS is only approved in the United States for unilateral lesioning (and therefore results in unilateral tremor control) and can be appropriate for patients with cognitive impairment, or for patients with unilateral predominant tremor.