Parkinson’s Disease Treatments: Medication, Therapy, and More

Parkinson’s disease (PD) is a progressive neurological condition. More specifically, it’s a type of brain problem called a movement disorder. It develops when specific nerve cells — in deep parts of the brain responsible for movement control — begin to decrease in number. These nerve cells are responsible for making dopamine, a chemical best known for the way it affects mood and pleasure. But dopamine has many other functions, too. It can affect things like digestion, blood pressure, and the way our muscles work.

So when the nerve cells that make dopamine start to die, levels of dopamine in key pathways in the brain drop. This leads to problems like tremors, slowed movement, and muscle stiffness. It also causes problems with balance and coordination. These are called motor symptoms. PD causes other symptoms, too, called nonmotor symptoms: Depression, sleep disturbance, constipation, and orthostatic hypotension.

PD slowly progresses over the course of a lifetime. And there isn’t a cure for PD yet. But available medications and other treatments help manage the symptoms of PD and slow its progression. 

How do you treat Parkinson’s disease?

The main treatment goal for Parkinson’s disease is to maintain dopamine levels in the brain. Medications that do this are called dopaminergic. They primarily address motor symptoms. It may be helpful to think of these medications in three broad categories: 

• Dopamine replacements

• Dopamine mimics (agonists)

• Dopamine savers

Experts recommend starting with one medication at the lowest possible dose to avoid potential side effects. Medication choice can depend on formulation, dosing frequency, and cost. It’s often necessary to adjust medications or add additional medications over time. Procedures are available, too, for those with symptoms that don’t respond to medications.

But these aren’t the only way to manage symptoms. People with PD may find it helpful to have a team of specialists to support them. This will include movement disorder physicians; occupational, physical, and speech therapists; and mental health professionals, depending on their symptoms.

Dopamine replacements: Carbidopa / levodopa

These are like dopamine supplements for the brain. The main example of this is carbidopa / levodopa (Sinemet). Research suggests it’s the most effective treatment for motor symptoms. 

These medications aren’t without their complications, though. Like many medications, they can cause side effects, and the benefits can wear off over time. 

Because of this, it’s recommended that people start with immediate-release formulations. They’re typically taken three times a day with meals. Your care team will work with you to find the lowest possible dose that improves your symptoms. This can take weeks to figure out, and you’ll probably need to make adjustments over time. 

Extended-release formulations of carbidopa / levodopa are available. There’s no evidence to suggest one works better than the other. But a longer-acting formulation may be a convenient option for people who don’t want to take medications multiple times a day. They can also be helpful for bedtime dosing in people who have a hard time with symptoms during the nighttime or early morning. 

Most forms of carbidopa / levodopa are taken orally (by mouth). But there’s also a levodopa-only inhaler, for quick relief of symptoms between oral doses. An infusion through a pump into the intestine is an option for people with swallowing difficulties. 

Dopamine mimics (or agonists)

These medications activate the receptors in the brain that make dopamine. Examples include oral medications like pramipexole (Mirapex) and ropinirole, which are available in immediate release and extended release forms. Rotigotine (Neupro) is available as a once-daily patch. Apomorphine (Apokyn) is an injectable for immediate relief of symptoms. A continuous infusion form is under review.

Initiating therapy with a dopamine agonist is possible. But it’s more commonly added to carbidopa / levodopa for treatment of advanced PD. Experts recommend against treatment with dopamine agonists for people at higher risk of side effects, such as older individuals or those with a history of cognitive problems. Withdrawal symptoms are possible if you stop taking dopamine agonists suddenly.

Dopamine savers: MAOIs and COMT inhibitors

These slow the natural breakdown of dopamine. They mainly include two different classes of medications called MAOIs (monoamine oxidase inhibitors) and COMT inhibitors (catechol-O-methyltransferase inhibitors). 

MAOIs and COMTs are often added to carbidopa / levodopa treatment in later stages. When levodopa begins to “wear off”, it can cause fluctuations in motor symptoms. Adding an MAOI or COMT can help improve this “wearing off” phenomenon.

MAOIs (selegiline, rasagiline, and safinamide) as solo treatment show modest improvement in symptoms in clinical studies. People who take an MAOI alone are likely to need additional treatment within 2 to 3 years. These medications are taken once or twice daily.

COMTs are approved only for combination treatment with carbidopa / levodopa. They include tolcapone, entacapone, and opicapone. Stalevo can be prescribed alone because it is a combination pill with entacapone and carbidopa / levodopa. These medications are taken several times per day, except opicapone, which is once daily. 

Other medications used to treat Parkinson’s

Carbidopa / levodopa is the first choice of treatment for PD in most situations. But other medications can be beneficial as well, depending on other factors like age, symptoms, and personal preference.

Amantadine 

Amantadine is an oral medication that works in several different ways to increase dopamine and slow its breakdown. Like MAOIs, it has only modest effects on motor symptoms from PD when used alone. But it can be an option for early Parkinson’s symptoms, especially in younger people with troublesome tremor. Typically, people who start taking amantadine need to move on to levodopa treatment within a year or two. 

Amantadine can also be a helpful add-on treatment to levodopa treatment in more advanced stages of PD. 

Anticholinergic medications 

Anticholinergic medications are the oldest type of treatment for PD. They work differently from the other PD medications. They’re less commonly prescribed today due to the likelihood of side effects. This type of medication may be appropriate for younger people with PD who have severe tremor and less stiffness and slowness. It’s not suitable for people at higher risk for memory problems, confusion, and hallucinations. Trihexyphenidyl and benztropine are common examples. Both come in tablet form to take two or three times a day.

Medication side effects

The downside of increasing dopamine levels in the brain is that dopamine circulates throughout the body, too. Extra dopamine can cause unpleasant side effects that can be hard to manage. Dopamine-enhancing medications can cause: 

• Nausea

• Lightheadedness 

• Hallucinations

• Uncontrolled movements 

• Daytime sleepiness

Some side effects, like daytime sleepiness, may be worse with dopamine agonists and with age. But dopamine agonists are less likely to cause uncontrolled movements than levodopa.

Also, as PD progresses, there’s a need for higher doses of these medications. This can increase unwanted side effects, which can make balancing medication doses challenging. And sometimes, it can be hard to tease out which symptoms are from PD and which are medication side effects.

Procedures for Parkinson’s disease

In later stages of Parkinson’s disease, additional treatments may be helpful. Examples include:

• Deep brain stimulators (DBS) are small devices implanted in the brain. They deliver painless electrical signals that help stimulate brain function. DBS can treat people with severe tremors and uncontrolled movements. 

• Lesioning procedures use high-energy beams to destroy targeted areas of the brain that contribute to tremors. This may be an option if you have a severe tremor that medication can’t control and when DBS isn’t a safe option. 

• Investigational treatments are in development and may provide future treatment options. These include gene therapy and a treatment that regenerates brain cells (through transplants or “stem cells”) that are lost in PD. 

Other therapies for Parkinson’s disease

Parkinson’s disease is a movement disorder. So it makes sense that people with PD often benefit from different types of physical therapy to help with their mobility and safety. But Parkinson’s symptoms reach beyond just its effects on movement. Improvements in function, communication, mental health, and caregiver support are possible with the variety of therapy options in PD.    

Physical therapy

Physical therapy can specifically improve:

• Balance: Improved balance can reduce the risk of falls. As many as 87% of people with PD have a fall at some point. And the risk is much higher over age 70.

• Posture: People with PD tend to lean forward when they walk. But they risk falling backward when they stand up. Physical therapists improve your awareness of center of gravity and posture recovery.

• Walking: PD can cause a “shuffling gait.” Therapists use audio and visual cues to improve fluidity of walking. And they can teach you how to do this at home.

• Mobility: People with PD often benefit from using devices like canes, walkers, and wheelchairs to safely move around and prevent falls. 

Occupational therapy

Occupational therapy helps overall function and performance of daily activities. It can help with:

• Tremor control: This can help you learn how to eat, dress, and bathe with unsteady hands. 

• Home safety: You might learn how to use devices like shower chairs, grab bars, bedside commodes, and more to reduce fall risk at home.

• Work adaptations: People with PD can customize voice-activated technologies for computers, cars, and equipment.

Speech and language therapy

PD can also affect speech and swallowing. Speech-language pathologists are trained to assist with these issues. They can help people with PD communicate better and swallow safely. 

Psychological support 

About 50% of people with PD will experience depression at some point after their diagnosis. Many experience changes in mood, feelings of sadness, or anxiety. Talk therapy, support groups, and antidepressants can help.

Lifestyle tips for Parkinson’s disease

Treatment for PD goes beyond medications and therapies. People living with PD can also benefit from: 

• Regular exercise: People who begin exercising after their Parkinson’s diagnosis have improved quality of life. In fact, just 2.5 hours of exercise per week can make a difference.

• Healthy diet and weight: People with PD can unintentionally lose weight. This is because eating and chewing become more difficult. Learning to prepare softer foods —  rich in nutrients and calories — can be helpful in maintaining weight and strength.

• Caregiver support: Social workers can help families with health services, financial challenges, and insurance options.

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Written by:

Mandy Armitage, MD

Mandy Armitage, MD, has combined her interests in clinical medicine with her passion for education and content development for many years. She served as medical director for the health technology companies HealthLoop (now Get Well) and Doximity.

Edited by:

Sophie Vergnaud, MD

Sophie Vergnaud, MD, is the Senior Medical Director for GoodRx Health. An experienced and dedicated pulmonologist and hospitalist, she spent a decade practicing and teaching clinical medicine at academic hospitals throughout London before transitioning to a career in health education and health technology.

Reviewed by:

Joshua Murdock, PharmD, BCBBS

Joshua Murdock, PharmD, BCBBS, is a licensed pharmacist in Arizona, Colorado, and Rhode Island. He has worked in the pharmacy industry for more than 10 years and currently serves as a pharmacy editor for GoodRx.

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