Propranolol is one of two recommended first-line therapies for essential tremor. Propranolol is given in divided doses, three times daily. Head tremor and voice tremor do not objectively respond to chronic propranolol therapy.^[1]

Small studies indicate that long-acting propranolol is as effective as the short-acting formulation; patients with exposures to both prefer the ease of the longacting formulation.^[2],^[3]

One year follow-up of patients taking propranolol showed a continued but sometimes reduced response to treatment; some patients needed dose increases.^[4]

Propranolol is contraindicated in patients with bronchial asthma and allergic rhinitis; selective β blockers might be considered in these cases. The American Academy of Neurology guidelines recommends the selective β blocker atenolol (100 mg daily) as “probably effective.”^[5]

Propranolol should be used with caution in patients with diabetes mellitus, as the adrenergic signs and symptoms of hypoglycemia can be masked. In the absence of contraindications, patients with stable heart failure due to left ventricular systolic dysfunction may take propranolol.^[6]

Patients who do not respond to propranolol do not respond to other β receptor blocking drugs. If a patient cannot take propranolol for some reason but could take an alternate non-selective β receptor blocker, three other non-selective β blockers have indications for use as second-line therapy. One multicenter crossover trial (n=145 completed study) reported that the response of tremor to arotinolol was significantly better than that to propranolol (30 mg daily arotinolol v 160 mg daily propranolol; P=0.002) on motor task assessment.^[7]

A randomized, double-blind, placebo-controlled trial in 24 patients found that sotalol (80 mg twice daily) was significantly better than placebo for the treatment of essential tremor (P<0.01); its effects were not compared directly with a response to propranolol.^[8] Nadolol was compared with placebo in a 10 person double-blind crossover trial and shown to have efficacy at 120 mg and 240 mg daily dose. The higher dose had no additional benefit.^[9]

At the time of this review, the American Academy of Neurology had produced guidelines for the management of essential tremor. The QualityStandards Subcommittee of the American Academy of Neurology initially published guidelines in 2005 and updated them in 2011. American Academy of Neurology guidelines make no specific dosing recommendations, the Italian guidelines do. The guidelines endorse propranolol and primidone as first-line treatment, and both recommend gabapentin and alprazolam as second-line treatment. They make no recommendations for polytherapy.^[10]