context: When Essential Tremor significantly interferes with daily activities, long-term drug treatment is needed. Drugs most commonly used to treat the condition include beta-blockers (propranolol) and an epilepsy drug called primidone ( Mysoline). Topiramate ( Topamax), another drug used to treat epilepsy and migraine, helps some people. With the use of medication, people with essential tremor may see improvement in their ability to control their tremor and improvement in activities such as drinking from a cup or using food utensils. More specialized motor functions, such as being able to thread a needle, may still be too difficult. However, for most people, essential tremor is not disabling. Your health care provider will determine which treatment is best for you based on your medical history. The goal of treatment is to help provide maximum improvement in function while minimizing the side effects of the medication you are taking. For people with mild Essential Tremor, drug therapy is usually not necessary. Tremors may be lessened by minimizing exposure to emotional stress and avoiding substances, such as caffeine and nicotine, which may increase tremor. In social situations, a person with mild tremor can take a beta-blocker or drink a small amount of alcohol, if such treatments are approved by a doctor. Although alcohol may lessen the tremor, there is the danger of slowly increasing your intake. The beta-blocker propranolol ( Inderal) has been used to treat essential tremor for more than 40 years. Other beta-blockers such as metoprolol ( Lopressor) also may be effective. It is not clear how Inderal reduces tremors, but the drug may work by blocking nerve impulses to the muscles. Approximately 50% to 60% of people taking Inderal experience some improvement in function, but total tremor suppression usually is not achieved. The greatest improvement is in hand and voice tremors. The drugs may be taken once a day (for longer-acting formulation) or twice a day, depending upon the formulation used. Beta-blockers are not right for everyone with Essential Tremor. Side effects of beta-blockers may include: Slowing heart rate Drop in blood pressure Fainting Apathy Fatigue Erectile dysfunction Depression Some of these side effects may require that the treatment be stopped. Be sure to tell your doctor if you: Have asthma or other bronchial conditions (beta-blockers may cause or worsen asthma symptoms) Have coronary artery disease or certain heart arrhythmias Have depression Have kidney disease Have liver disease Have diabetes Are pregnant or nursing While you are taking Inderal, your health care provider will monitor your heart rate and blood pressure. In general, Inderal works over a long period of time to suppress tremors; however, nearly 10% of people will develop tolerance to the drug after a year. This means that the drug stops being effective when given in the same dose as when you began treatment. In this case your doctor will suggest another medication or treatment. Primidone ( Mysoline) is an anti-seizure drug that is also effective for treating essential tremor. It is most useful for people with hand tremor. Although it is not clear how it works, Mysoline appears to be as effective as Inderal, with significant suppression of tremor in most patients. However, as with Inderal, a percentage of people may develop tolerance to the treatment after about a year. In most cases, Mysoline is given to people who do not tolerate Inderal. Mysoline also can be given in addition to Inderal to improve symptoms. Mysoline may cause unwanted side effects in the short term (within the first few days of starting treatment); however, these side effects diminish with longer use. Side effects of Mysoline may include: Difficulty walking Dizziness Nausea Sleepiness Confusion Fatigue Serious complications with the drug are rare but could include blood cell and bone marrow problems. Your health care provider will check your blood counts every six to 12 months to screen for these problems. Mysoline has a drug interaction with phenobarbital, so the drugs should not be taken together. Before taking Mysoline, be sure to tell your doctor if you: Are pregnant or nursing Are taking any medications ( Mysoline may interact with several different types of drugs.) Have kidney or liver problems Have blood count problems In addition, you should avoid alcoholic beverages while taking Mysoline. Do not stop taking the drug suddenly or switch brands without first consulting with your health care provider. Topamax is widely used for epilepsy and migraine. Many doctors prescribe it for Essential Tremor. It is important to start with a very low dose and slowly increase the dose to avoid sleepiness. Many patients may experience a feeling of mental dullness or drowsiness and should consult with their doctor about adjusting the dose. As many as 30% to 40% of people do not tolerate this drug in higher doses. Experts use Neurontin for short-term treatment of Essential Tremor affecting the hands, although it is not known how the drug works. In most cases, it is not used in conjunction with other drugs. Side effects of Neurontin are rare but include: Sedation Walking difficulties Irritability Weight gain Some people with Essential Tremor report symptom relief after drinking a glass of wine or a cocktail. The effect usually lasts about an hour, but rebound tremors can occur after this time. It is generally not recommended that you attempt to treat essential tremor symptoms with alcohol. Benzodiazepines ( Ativan, Klonopin, Valium, and Xanax) may help people whose Essential Tremor is not improved by other drugs. These drugs appear to relieve tremors associated with emotional stress or anxiety. Side effects of benzodiazepines include confusion, memory loss, and sedation. For most people this is not a good long-term solution. Botox (subtype A) and Myobloc (subtype B) are the brand names for botulinum toxin, which can be used to treat some movement problems. The drugs work by weakening muscles to reduce tremor. The drug also can be used to treat voice or head tremors. This treatment involves an injection once every three months. Do not take this drug if you are pregnant or if you have myasthenia gravis, post-polio syndrome, or Eaton- Lambert syndrome. Side effects of Botox are rare, but may include excessive muscle weakness or loss of appetite. Currently, there is no evidence that alternative treatments are beneficial in treating Essential Tremor. Patients who have tremors that worsen with emotional stress may find relaxation therapies helpful at temporarily easing symptoms. Some herbal supplements may make tremor worse. Always consult your doctor before trying any alternative therapy.