Essential Tremor Treatment: Propranolol and Primidone

If you have an essential tremor, you may be experiencing trouble with your daily activities. And you might be wondering if there are treatments for essential tremor that may help relieve your symptoms. Or perhaps you’ve already heard about treatments for essential tremor, like propranolol, but you aren’t sure if they’re right for you. Let’s take a look at your options for essential tremor treatment.

What is essential tremor?

An essential tremor is an involuntary, shaking movement that usually happens in your hands or arms. There are many types of tremors, but essential tremors are the most common type. 

You tend to develop an essential tremor as you get older. Tremors usually start gradually and can affect your ability to carry out daily activities. 

Treatment for essential tremor

There’s no cure for essential tremor. Treatment focuses on providing symptom relief so that you can perform your usual activities. But not everyone with an essential tremor has the same experience. Some people have more tremor activity and have a hard time completing tasks. Others have very little trouble doing activities and may choose not to treat their tremor. 

Treatment for essential tremor varies from person to person and depends on their needs. Treatment options include:

• Medication

• Medical procedures

• Lifestyle changes

• Adaptive equipment

The response to these treatment options also varies. What works for one person may not work for another. Over time, essential tremors usually get worse. So you may stop responding to initial therapy or need to try additional therapies. 

Essential tremor medications

Anyone with an essential tremor can choose to start treatment with medication. There are several medications that can help treat essential tremors. But propranolol and primidone are the most popular. And researchers have studied them the most. Both work equally well, although propranolol is often preferred because it has fewer side effects. But other factors, like your medical history and personal preferences, might make primidone a better option for you. 

Propranolol

Propranolol (Inderal) is a beta blocker. People usually start with low doses (60 mg to 80 mg per day) of this medication 2 to 4 times per day. Then they go up on their dose little by little each week until their tremor improves. Studies show that propranolol can decrease symptoms of essential tremor by 50%. People usually notice benefits 1 week after starting propranolol.

Propranolol can also help if you only experience tremors in stressful situations — like social settings or public events. Low-dose, immediate-release propranolol before these events can improve essential tremor symptoms. 

But propranolol doesn’t improve tremor symptoms for everyone. Some people may need to try a different medication. 

Over time, people may also stop responding to propranolol. In these cases, people may either need to take a higher dose or try an additional or different medication. 

Side effects

Propranolol can also cause side effects, like:

• Lightheadedness

• Fatigue

• Low heart rate

• Erectile dysfunction

Studies show that about 17% of people have to stop taking propranolol because of side effects. 

People with certain medical conditions may not be able to take propranolol. These conditions include:

• Heart block

• Heart failure

• Asthma

• Type 1 diabetes

Primidone

Primidone (Mysoline) is an anti-seizure medication. People usually start on a low dose (25 mg) and take it once a day, at bedtime. Then they slowly go up on the dose each week. It can take up to 2 weeks to start seeing improvements in tremor symptoms. Studies show that primidone can decrease tremors by 50%. And primidone can also help lessen voice tremors. 

Primidone doesn’t work for everyone. If primidone doesn’t work for you, your healthcare provider might recommend another medication, like propranolol. Or they might recommend an additional medication to primidone. 

Side effects

Primidone causes several side effects, including:

• Drowsiness

• Nausea and vomiting

• Dizziness

• Fatigue

• Vertigo

• Unsteadiness when walking 

Many people have a hard time with these side effects and need to stop taking primidone. 

Other medications

Some people don’t get any relief from propranolol or primidone. While there are other medications that you can take, studies show that they don’t work as well. Other medication options include:

• Alprazolam 

• Clonazepam 

• Gabapentin

• Olanzapine 

• Clozapine 

Researchers are also looking into other medications that may help with essential tremor. 

Therapy for tremor

In addition to medications, many people work with physical and occupational therapists. Therapy won’t decrease tremor symptoms. But it can help you learn new ways to navigate daily tasks.

Physical therapy focuses on resistance training. This can increase your strength and coordination so that you can perform tasks.

Occupational therapists can help you work on new ways to complete your daily activities. They can also show you how to use adaptive equipment, like wrist weights, weighted pens, computer equipment, and utensils. Other types of adaptive equipment can help people with tasks like dressing, cooking, and eating. Studies show that most people report being able to complete tasks more easily when using adaptive equipment properly. 

How can I reduce my tremor naturally?

Many people are looking for ways to decrease their tremor without medication. In addition to therapy, there are several things you can do to reduce your tremor naturally.

Cut down on caffeine

Some things can worsen essential tremors, including caffeine, stress, and certain types of medications. Minimizing or eliminating caffeine can help naturally decrease your tremors.

Switch medications that worsen tremors

You can also talk to your healthcare provider about switching medications that can worsen your tremor. These include:

• Antidepressants, like SSRIs and tricyclic antidepressants

• Steroids 

• Amiodarone

• Albuterol

• Some anti-seizure medications 

• Lithium

You should never stop or decrease any of these medications on your own. It can lead to serious health problems. Be sure to contact your healthcare provider.

Use stress-reducing techniques

Stress and anxiety can also worsen essential tremors. Some techniques that can help decrease symptoms include:

• Biofeedback

• Deep breathing exercises

• Relaxation techniques

• Meditation

You can work with a therapist to develop and perfect these techniques.

Tremor-cancellation devices

Tremor-cancellation devices are a type of adaptive device that can help decrease tremor symptoms. Some devices use weights, while others deliver tiny electrical stimulations. Not all tremor-cancellation devices are FDA approved. It’s best to work with your healthcare provider and occupational therapist to decide if a device is right for you.

CBD products

Researchers are studying whether CBD products can treat essential tremors. So far there are studies showing CBD helps treat essential tremor symptoms in mice. There are clinical trials underway looking at whether CBD also helps essential tremor symptoms in humans. 

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Written by:

Ronald W. Dworkin, MD, PhD

Ronald W. Dworkin, MD, is a board-certified anesthesiologist who has been practicing anesthesiology in a community hospital for 30 years. He has taught in the honors program at George Washington University for over 10 years and works as a senior fellow at the Hudson Institute.

Edited by:

Patricia Pinto-Garcia, MD, MPH

Patricia Pinto-Garcia, MD, MPH, is a medical editor at GoodRx. She is a licensed, board-certified pediatrician with more than a decade of experience in academic medicine.

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