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Benign Essential (Familial)
Tremor
The cause of benign essential
tremor is uncertain, but it is sometimes inherited in an autosomal dominant
manner. Tremor may begin at any age and is enhanced by emotional stress. The
tremor usually involves one or both hands, the head, or the hands and head,
while the legs tend to be spared. Examination reveals no other abnormalities.
Ingestion of a small quantity of alcohol commonly provides remarkable but
short-lived relief by an unknown mechanism.
Although the tremor may become more
conspicuous with time, it generally leads to little disability, and treatment is
often unnecessary. Occasionally, it interferes with manual skills and leads to
impairment of handwriting. Speech may also be affected if the laryngeal muscles
are involved. In such circumstances, propranolol may be helpful but will need to
be continued indefinitely in daily doses of 60–240 mg. However, intermittent
therapy is sometimes useful in patients whose tremor becomes exacerbated in
specific predictable situations. Primidone may be helpful when propranolol is
ineffective, but patients with essential tremor are often very sensitive to it.
They are therefore started on 50 mg daily, and the daily dose is increased by 50
mg every 2 weeks depending on the response; a maintenance dose of 125 mg three
times daily is commonly effective. Occasional patients fail to respond to these
measures but are helped by alprazolam (up to 3 mg daily in divided doses).
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