Correspondence

Essential Tremor

N Engl J Med 2002; 346:709-710February 28, 2002

Article

To the Editor:

In his article on essential tremor (Sept. 20 issue),1 Louis does not mention alcohol. Ethanol in small doses usually stops the tremor, and this finding may be useful in diagnosis. Some people may use ethanol to hide their tremor; they risk alcohol dependence as a result.

Primidone is noted to be an effective agent, but as Louis points out, nausea and vomiting are common when treatment with this drug is initiated and may lead to its discontinuation. It should be noted that there is tachyphylaxis with respect to these effects. Use of a very low starting dose (25 mg daily) with gradual increases in the dose over a month or so can improve tolerability and compliance with this medication.

Stanley van den Noort, M.D.
University of California at Irvine, Irvine, CA 92697
svandenn@uci.edu

1 References

1. 1

   Louis ED. Essential tremor. N Engl J Med 2001;345:887-891
   Full Text | Web of Science | Medline

Author/Editor Response

Dr. Louis replies:

To the Editor: I thank Dr. van den Noort for noting the use of ethanol in the treatment of essential tremor. Growdon et al.1 documented a 46 to 83 percent decrease in the amplitude of tremor, measured by accelerometry, in five patients with essential tremor 10 to 15 minutes after the oral ingestion of ethanol. In another study, the intravenous infusion of ethanol, but not placebo, significantly reduced the amplitude of tremor in 15 patients with essential tremor.2 With the use of positron-emission tomography, it has been found that ethanol ingestion leads to the suppression of tremor and to bilateral decreases in cerebellar blood flow.3

One third of patients with essential tremor report that the tremor responds to ethanol,4 although many are reluctant to use ethanol for a variety of reasons. First, older patients may be taking medications that are contraindications to the concurrent use of ethanol. Second, although some patients report that a glass of wine during an evening social event will reduce the amplitude of their tremor, they are reluctant to consume ethanol during daytime hours, particularly while working, because of its cognitive and soporific effects. Third, there is concern about ethanol dependence and the social stigma of its use.

Lower doses of primidone have been reported anecdotally to result in less nausea and vomiting than higher doses. However, the tolerability of various starting doses needs to be studied in a double-blind manner.

I want to note that in the third paragraph of my article, the term “akinetic tremor” should have been “a kinetic tremor.”

Elan D. Louis, M.D.
College of Physicians and Surgeons of Columbia University, New York, NY 10032
edl2@columbia.edu

4 References

1. 1

   Growdon JH, Shahani BT, Young RR. The effect of alcohol on essential tremor. Neurology 1975;25:259-262
   Web of Science | Medline

2. 2

   Koller WC, Biary N. Effect of alcohol on tremors: comparison with propranolol. Neurology 1984;34:221-222
   Web of Science | Medline

3. 3

   Boecker H, Wills AJ, Ceballos-Baumann A, et al. The effect of ethanol on alcohol-responsive essential tremor: a positron emission tomography study. Ann Neurol 1996;39:650-658
   CrossRef | Web of Science | Medline

4. 4

   Koller WC, Busenbark K, Miner K. The relationship between essential tremor and other movement disorders: report on 678 patients. Ann Neurol 1994;35:717-723
   CrossRef | Web of Science | Medline

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