Because of the low quality of the majority of articles included, there was insufficient information available to properly verify the originally reported diagnoses of medication‐induced tremor. Therefore, we accepted the original authors’ diagnoses, possibly leading to bias in our review. Another limitation is the necessity of converting subjective into objective data, possibly inducing errors. Also, because of the scarcity of studies and the lack of identification of the causative agents, we could not subcategorize the results, leading to generalized conclusions. Lastly, we used the number of articles that examined the intervention as a way of determining the power of each intervention effect because the number of different sources can be important to establish the credibility of the results.
Tips for Examining a Patient With Tremor
- The characteristic history of essential tremor is the presence of a hand tremor that frequently interferes with activities of daily living such as eating, drinking, pouring, handling utensils, dressing, and using keys or other household tools.
- While ancillary tests, such as metaiodobenzylguanidine (MIBG) cardiac scans10 and DAT scans can be confirmatory, a proper history, with a focus on medication review, nonmotor features, and physical exam can help guide one towards the correct diagnosis.
- Finally, we propose a treatment paradigm to aid clinical decision making.
- Drug-induced movement disorders can range from tremors to life-threatening syndromes.
- Despite the lack of high‐quality evidence, our data clearly identify at least 3 medications that appear to have good‐to‐excellent effectiveness (propranolol) or a trend toward good‐to‐excellent effectiveness (tetrabenazine and metoprolol).
While ‘non-essential tremor’ isn’t a formal diagnosis it is often used to refer to “tremors that have an identifiable cause” versus essential tremor, which is often idiopathic (no clear cause). MRgFUS could potentially be a more applicable tool in patients with psychiatric conditions where the use of DBS can be complicated. Recently, bilateral MRgFUS has been shown to be effective for ET if one side is done at a time and sufficient time elapses between procedures and was recently approved by the FDA (17, 29, 30).
- Similarly, amantadine can help with concurrent oro-buccal-lingual dyskinesia.
- Essential tremor is a chronic, progressive syndrome that primarily presents with an action tremor involving the arms and hands.
- Lesions of cerebral structures implicated in tremorogenesis (Fig. 1) may cause tremor.
- Unlike many non essential tremors, this happens when the body is at rest.
For Patients
The small number of studies, and reliance on case reports may suggest publication bias and hinder generalization. Additionally, the unknown pathophysiological process and lack of definitive diagnostics or biomarkers in drug-induced tremor render uncertainty in diagnosis. MRgFUS thalamotomy is commonly used to treat tremor via ablation of the ventral intermediate nucleus (VIM) of the thalamus (17). MRgFUS has been explored since the 1950s, but recent technological advances have allowed it to be used safely to target precise structures in the deep brain (18). In 2016, the FDA approved MRgFUS thalamotomy for essential tremor (ET) (15). MRgFUS thalamotomy has also been found to be effective for other non-ET tremors such as Parkinson’s disease (PD) tremor (15, 16).
Table 1.
Besides direct benefits related to actions against sodium channels in the neuronal membrane, the efficacy of primidone is related to the metabolites such as phenobarbital and phenylethylmalonamide.53 Confusion, ataxia, and nausea are side effects more commonly seen in older patients using high doses. A stepladder approach for treating essential tremor symptoms is proposed (FIGURE 5-4), and shared decision making between the patients and their clinical providers at each step is encouraged. When the symptoms are mild, nonpharmacologic therapies could be the first consideration. Occupational therapists can help develop a practical, individualized approach. An occupational therapy evaluation will focus on modification of the functional task and encourages the use of compensatory strategies such as proper body mechanics and core stability for hand control. Several adaptive devices, such as weighted spoons, forks, utensils, or rocker knives; weighted pencils and pens; and modified computer mouses and keyboards, are available for a more efficient task performance.
The tremors may not happen all of the time, but they’re likely to occur within the first hour of taking medication. If you find that this happens to you, take note of the medications you took before your tremors. This can help you and your doctor figure out which specific medication, or combination of medicines, is causing your symptoms. Dystonias are involuntary movements characterized by intermittent or sustained muscle action (Table 2).
Tremor can occur secondary to many drugs, including SSRIs, lithium, tricyclic antidepressants, antiepileptics (particularly valproate), bronchodilators, amiodarone and immunosuppressives. Another underlying aetiology, such as Parkinson’s disease, essential tremor or hyperthyroidism, needs to be excluded. Drug-induced tremor is a common side effect of lithium with an occurrence of approximately 25% of patients. Cessation of the offending drug can be difficult, and many medical treatments for drug-induced tremor are ineffective.
What Can Be Done to Treat My Tremors?
Although results indicate mainly good‐to‐excellent effect in monoamine reuptake inhibitors, this was driven almost exclusively by studies with tetrabenazine. In order to understand the phenomenology of MIT, discussed below, we will briefly review the basics of tremors.17,18 Tremors are typically characterized by rhythmic oscillations of a body part about a joint and are best classified by the situation in which it occurs. Resting tremor (as typically occurs in DIP or PD) is commonly 4–6 Hz in frequency and occurs when the affected body part is fully supported without ongoing voluntary muscle contraction. Action tremor, in contrast, occurs with voluntary movement and can be divided into postural tremor and kinetic tremor. Postural tremor occurs classically when maintaining the arms in an outstretched position against gravity. Kinetic tremor includes tremor that is task specific or with goal-directed movements.
Types of Non-Essential Tremors
In contrast to idiopathic Parkinson’s disease, drug-induced parkinsonism usually presents as a symmetrical akinetic rigid syndrome which develops over days to weeks to months following ingestion of the offending drug. Additionally, there is a poor response to typical antiparkinsonian drugs, including levodopa, dopamine agonists and anticholinergic drugs. Cessation of the offending drug usually results in complete resolution of the disorder.
OnabotulinumtoxinA was targeted mainly to the left sternocleidomastoid, right splenius capitis, and right longissimus capitis muscles, which helped control her headaches, neck pain, spasms, and tremor. Other miscellaneous medications that have been rarely reported to cause DIP are listed in Table 1. These medications include antiarrhythmics, some antibiotics, some immunosuppressants, and endocrine agents. There is a paucity of literature that deals with the mechanisms of MIT, with most manuscripts only describing the frequency and clinical settings where MIT is observed. That being said, MIT emanates from multiple mechanisms depending on the drug and it often takes an individualized approach to manage MIT in a given patient. Finally, inquire about any warning signs or symptoms that would necessitate immediate medical attention.
The mainstay of treatment includes resuming anti-parkinsonian drugs, usually via nasogastric tube because of the dysphagia resulting from severe parkinsonism. Intermittent apomorphine injections or a continuous infusion may be required in moderate–severe cases. These medications work by stabilizing nerve signals in the brain and spinal cord. While effective for many individuals, anticonvulsants may cause side effects such as drowsiness or dizziness. Careful titration of the dosage under medical supervision can help minimize these effects while maximizing tremor control. While beta-blockers can be highly effective, they may not be suitable for everyone.
It is important drug-induced tremor: symptoms, diagnosis treatments to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Contact your provider if you are taking a medicine and a tremor develops that interferes with your activity or is accompanied by other symptoms. Severe tremor can interfere with daily activities, especially fine motor skills such as writing, and other activities such as eating or drinking. CT and MRI scans are done by a computer and allow your doctor to see your brain.
Anywhere from 5 to 36 percent of people taking antipsychotics may develop akathisia. The institution of Dr Wagle Shukla has received research support from the National Institutes of Health. It is important to note that unlike the diagnostic criteria for Parkinson’s disease, bradykinesia is not required for the diagnosis of DIP. Consider working with an occupational therapist who can provide personalized strategies for managing daily activities and recommend adaptive devices to enhance independence. Remember, seeking help is a sign of strength and can significantly improve overall well-being and tremor management. Vitamin B complex, particularly B1 (thiamine) and B12, is essential for proper nerve function.
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